Sworn Statement Form - Virginia
DEPARTMENT OF SOCIAL SERVICES Page 1 of 2
(Model Form)
SWORN STATEME NT OR AFFIRMATION FOR CHILD DAY PROGRAMS
Please Print
________________________________________________________________________________________________
Last Name First Middle Maiden Social Security Number
________________________________________________________________________________________________
Current Mailing Address Street, P.O. Box #, Apt. # City State Zip Code
________________________________________________________________________________________________
Name of Licensed/Registered Street, P.O. Box #, Apt. # City State Zip Code
Approved Facility/Provider
Please respond to all four (4) questions below:
1. Have you ever been convicted of or are you the subject of pending charges of any crime within the Commonwealth
of Virginia?
Yes (convicted in Virginia) Yes (pending in Virginia) No
If yes to convicted or pending, specify crime(s): _____________________________________________________
____________________________________________________________________________________________
2. Have you ever been convicted of or are you the subject of pending charges of any crime outside the Commonwealth
of Virginia?
Yes (convicted outside Virginia) Yes (pending outside Virginia) No
If yes to convicted or pending, specify crime(s) and state, or other location: _______________________________
____________________________________________________________________________________________
3. Have you ever been the subject of a founded complaint of child abuse or neglect within the Commonwealth of
Virginia?
Yes (in Virginia) No (in Virginia)
4. Have you ever been the subject of a founded complaint of child abuse or neglect outside the Commonwealth of
Virginia?
Yes (outside Virginia) No (outside Virginia)
If yes, specify state, or other location: ______________________________________________________________
I hereby affirm that the information provided on this form is true and complete. I understand that the
information is subject to verification and that making a materially false statement or affirmation is a Class I
misdemeanor.
________________________________________________________________ ______________________________
Signature Date
032-05-0160-09-eng ( 07/14)
Page 1/2
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Sworn Statement Form - Virginia PDF
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