OCFS- 6005 (5/2014) FRONT

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

CAREGIVER CRIMINAL CONVICTION STATEMENT

Family Day Care, Group Family Day Care Programs & Small Day Care Centers

INSTRUCTIONS:

ALL caregivers must complete and sign this Criminal Conviction Statement regardless of conviction status

This form is in addition to being fingerprinted

Please PRINT clearly

Program Name:

License/Registration Number:

Caregiver Name:

Date of Birth (mm/dd/yyyy):

CAREGIVER ROLE: (Check one)

Provider	Assistant	Substitute
CONVICTION STATEMENT

Have you previously completed a Conviction Statement?

No, this is the first conviction statement I am signing for child day care.

Yes, I have signed a previous conviction statement for child day care and

All of the following convictions (if any) were previously reported OR

I have added new convictions since the last statement.
Certification

In accordance with Section 390-b(1)(b) of the Social Services Law, I certify that to the best of my knowledge and belief:

I have

i HAVE NOT been convicted of a crime in New York State or another State or Federal Court.

(A crime is a misdemeanor or felony only; this does not include violations. You do not need to disclose crimes that the court designated with a "Youthful Offender" status.)

Record of All Convictions	EXAMPLE:	Type of Crime	Penal Code Section	Date of Conviction	County or Court of Arraignment
Petit Larceny	155.25	5/1/2013	Albany
Complete the information below and submit with record of conviction or certification of court arraignment. In addition, you may provide written justification on the back of this sheet, explaining why you should be allowed to care for children regardless of any conviction.

Type of Crime	Penal Code Section

(if known)	Date of Conviction

(mm/dd/yyyy)
County or Court of Arraignment

To the best of my knowledge the information provided above is true and accurate. I understand that my failure to truthfully and accurately state whether I have been convicted of a crime and/or to provide truthful and accurate information concerning the conviction(s) may constitute grounds for dismissal or denial of employment, or suspension, limitation or revocation of the license or registration to provide child care at this site.
SIGNATURE:	DATE: (mm/dd/yyyy):
(continued on reverse side)

OCFS- 6005 (5/2014) REVERSE

CAREGIVER CRIMINAL CONVICTION STATEMENT (continued)

Please provide your justification below, explaining why you should be allowed to care for children despite your conviction history. You may attach your own sheets of paper if you need more space.

OCFS- 6005 (5/2014) FRONT

2015-09-14