LICENSING RECORD CLEARANCE REQUEST
FOSTER HOME/ADOPTIVE HOME
*ONLY FOR THOSE REQUIRIING FINGERPRINTS (Licensee/Applicant)*
Michigan Department of Health and Human Services
Division of Child Welfare Licensing
SECTION I: REQUESTOR INFORMATION (Must be completed by licensing consultant/worker)
Agency Name and Address:	CPA License Number
ENTER ADDRESSEE NAME ENTER ADDRESSEE CARE OF ENTER ADDRESSEE PO BOX OR STREET ENTER ADDRESSEE CITY/STATE/ZIP
Fold Mark
Directions for Completing Form:	LIVESCAN Fingerprint Request
Please read the accompanying instructions before completing this form. Please type or print CLEARLY so that the information provided can be read. Mail completed form to DCWL Central Office or address noted in box below.	(Must be filled in prior to returning) TCN#: ____________________________ Date Fingerprinted: __________________ Type of Picture ID presented: ___________________________ AWP-Private Adoption-Agency ID: 68466H-Fee AWF-Foster Parent-Agency ID: 68465P-Voucher AWA-MDHHS Child/Adoption-Agency ID: 68464J-Voucher
Worker’s Information
Worker’s Name	Email	Telephone Number
Applicant Information
Licensee/Applicant Name Full (Last, First)	County	DCWL Licensee Number (If assigned)
Date of Birth

SECTION II: CLEARANCE INFORMATION (To be completed by applicant or other person to be cleared – if more than one person is named on the application, each is to complete a CWL-1326) Print Clearly
Last Name	First Name	Middle Initial
MiSACWIS Person ID (AWF/AWA only):	Social Security #
Have you always lived in Michigan?
No Yes
If you have lived outside of Michigan in the past 5 years, please list the states/countries where you have lived:
Have you ever:
Been convicted of a crime, felony or misdemeanor?
No Yes (If yes, explain) ________________________________________________
Been substantiated for abuse or neglect of children or adults?
No Yes (If yes, explain) _________________________________________________
Type, Location, and Date of Conviction(s) or Substantiations: (for additional space attach separate sheet)
My signature certifies that I have reviewed the information on the back of this form.
Signature of Person or Guardian to be Cleared	Date
SECTION III: CENTRAL RECORDS CLEARANCE (DCWL Use Only)
Address on Michigan Public Sex Offender Registry?	Initials/Clearance Date
No Yes
Secretary of State Discrepancy?	Initials/Clearance Date
No Yes
Individual on Central Registry?	Initials/Clearance Date
No Yes
Individual with MiSACWIS/CPS History?	Initials/Clearance Date
No Yes
Previous Registration/License	Initials/Clearance Date
No Active Closed
Previous Registration/License Number:	Adverse Action?
Yes
SECTION IV: CONVICTION CLEARANCE
(DCWL Use Only)
LICENSING RECORD CLEARANCE REQUEST instructions
The purpose of this form is to:
1. Produce a Department of State Police check regarding the possible existence of a conviction record.
2. Produce a Michigan Department of Health and Human Services Central Registry File check regarding the possible existence of a substantiated child abuse or neglect record.
3. Produce a Division of Child Welfare Licensing (DCWL) Files check against current or previous licensee status of the applicant in any county of the state.
Instructions for processing: The Licensing Clearance (CWL-1326) must be taken with you at the time the FBI fingerprint is conducted. Note: the TCN# will be filled by the Fingerprint Specialist and must be completed prior to submitting the form.
Foster Parents/Adoptive Parents (AWP, AWF & AWA): Live Scan Fingerprint Request is required for foster home or adoptive applicants and licensees.
Private Adoption - If your licensing record clearance form has an AWP code (Private Adoption) at the bottom of the upper right hand box titled LIVESCAN FINGERPRINT REQUEST, you may select a fingerprint vendor from a Private Live Scan Vendor at: http://www.michigan.gov/msp/0,1607,7-123-1589_1878_8311-237662--,00.html.
MDHHS Adoption & Foster Parent - If your licensing record clearance form has an AWA code (MDHHS Child/Adoption) or an AWF code (Foster Parent) at the bottom of the upper right-hand box titled LIVESCAN FINGERPRINT REQUEST, you must be registered and scheduled for fingerprinting. Contact the county MDHHS office or private agency licensing to get your fingerprint appointment scheduled.
The existence of a conviction record does not necessarily disqualify an applicant for licensure. However, it does provide DCWL and the child placing agency with information, which will be carefully evaluated by licensing staff.
A failure on the part of an applicant to provide DCWL with accurate and truthful information and the authorization requested on this form may be sufficient cause to deny issuance of a license or certificate of registration.
I am aware that Michigan Department of State Police Records will be checked for information regarding criminal convictions under authority of the Child Care Organizations Act 116 of 1973.
I am aware that the Michigan Department of Health and Human Services Central Registry will be checked for information concerning substantiated child abuse and neglect.
I certify that the information I have given on the form is, to the best of my ability, true and correct.
The Department may perform this check at any time while I am licensed.
I understand the personal information and fingerprints submitted by live scan are used to search against criminal identification records from both the Michigan State Police (MSP) and Federal Bureau of Investigation (FBI). I hereby authorize the release of any records to the person or agency listed above. I further understand MSP and the FBI may also retain the submitted information and fingerprints as permitted by the Federal Privacy Act of 1974 (5 USC § 552a(b)) for routine uses beyond the principal purpose listed above. Routine uses include, but are not limited to, disclosures to: governmental authorities responsible for civil or criminal law enforcement, counterintelligence, national security, or public safety.
28 CFR §16.34- Procedure to obtain change, correction or updating of identification records.
If, after reviewing his/her identification record, the subject thereof believes that it is incorrect or incomplete in any respect and wishes changes, corrections or updating of the alleged deficiency, he/she should make application directly to the agency which contributed the questioned information. The subject of a record may also direct his/her challenge as to the accuracy or completeness of any entry on his/her record to the FBI, Criminal Justice Information Services (CJIS) Division, ATTN: SCU, Mod. D2, 1000 Custer Hollow Road, Clarksburg, WV 26306. The FBI will then forward the challenge to the agency which submitted the data requesting that agency to verify or correct the challenged entry. Upon the receipt of an official communication directly from the agency which contributed the original information, the FBI CJIS Division will make any changes necessary in accordance with the information supplied by that agency.
**DISCLAIMER: ALL FINGERPRINTS PROCESSED WITH INCORRECT FINGERPRINT CODES ARE THE RESPONSIBILITY OF THE REQUESTING AGENCY. MSP WILL CHARGE FOR SECOND REQUESTS DUE TO INCORRECT FINGERPRINT CODES. **I am aware that Michigan Department of State Police Records will be checked for information regarding criminal convictions under authority of the Child Care Organizations Act 116 of 1973.
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.
Authority: Child Care Organizations Act 116 of 1973 as amended Completion: Required Consequence: Registration/Licensure may be denied or revoked.