PS-042-FF (12-08) |ARIZONA DEPARTMENT OF ECONOMIC SECURITY (DES)
Child Protective Services (CPS) | | |REQUEST FOR CHILD PROTECTIVE SERVICES REPORT

|CPS reports are confidential and can be released only to those individuals and agencies authorized by law (A.R.S. § 8-807 and § 41-1959). This form is to be |
|used by persons who believe that a report has been made about them. Parents may request a report on behalf of their children and legal guardians may request |
|reports on behalf of the child. This form is not to be used to release other types of legally authorized information. DES will strike out (redact) information |
|as required by law including the identity of the reporting person. The requester should provide information as completely and accurately as possible to |
|facilitate the search. Your signature must be notarized, or identity verified. Mail the notarized form to the Child Abuse Hotline (050C-3), P.O. Box 44240, |
|Phoenix, AZ 85064-4240; or you may deliver the completed form to your local CPS office and it will be forwarded to the Hotline for response. Retain a copy of |
|the form for your records. You will be provided with copies of any reports you are entitled to or will be notified that there are no reports. |
|*DES requests that you provide your Social Security number. The Social Security number is not required to be provided by you in order to obtain the records you |
|seek. However, supplying one or more of these numbers will greatly assist in matching your request to the correct individual(s), if any, in the CPS electronic |
|records systems. |
|*The records request form you provide to CPS will be maintained for the period required by state law, but the Social Security number(s) will only be shared or |
|released pursuant to law or a court order. If you do not supply one or more Social Security number(s) as requested, CPS may not be able to identify the records |
|you seek. |
|REQUESTER’S NAME (Last, First, M.I.) |BIRTHDATE |*SOC. SEC. NO. |
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|REQUESTER’S ADDRESS (No., Street, City, State, ZIP) |REQUESTER’S PHONE NO. |
| |Work: |Home: |
|REQUESTER’S MAILING ADDRESS IF DIFFERENT FROM ABOVE (No., Street, P.O. Box, City, State, ZIP) |APPROXIMATE DATE(S) OF THE CPS REPORT(S) |
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|CHILD VICTIM’S NAME |OTHER SPELLINGS |BIRTHDATE |SOC. SEC. NO. |
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|CHILD VICTIM’S NAME |OTHER SPELLINGS |BIRTHDATE |SOC. SEC. NO. |
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|CHILD VICTIM’S NAME |OTHER