Client MUST bring completed form & photo ID with him/her.

Transaction Information (This MUST be received within 24 hours of placement)
Emergency Placement
In Exigent Circumstances with a Relative or Non-Relative & with NCIC Name Check / Non-Emergency Placement
With a Relative or Non-Relative & No NCIC Name Check
If resubmitting, TCR Number: (Begins with IFCS followed by 16 numbers)
Caseworker’s Name: / Phone: / Unit:
Name of Child(ren) to be placed:
FSFN # / Date Called to Hotline: / Plcmnt Made Y N / Date:

PERSONAL INFORMATION

Name:
Maiden Name/Nickname/Alias:
SSN: / DOB: / POB:
(e.g., 123456789) / (YYYYMMDD) / (Birth State or Birth Country)
Country of Citizenship: / (e.g., U.S.)
Residence Address: / City:
Zip Code: / Phone: / Cell Phone:
Employer Name and Address:

Physical Description (please check ONE in each category or complete as indicated)

Gender: Female | Male
Race: Asian | Black | Native American | White | Unknown
Color of Eyes: Black | Blue | Brown | Green | Gray | Hazel Maroon | Multicolor | Pink
Hair Color: Bald | Black | Blonde or Strawberry | Blue | Brown Green | Gray/Partially Gray | Orange
Purple | Pink | Red or Auburn | Sandy | White | Unknown
Height: / Weight: / Signature: / Date:
*By signing this form and completing your fingerprints, you understand that any criminal history will be verified through the FBI, and you are certifying that the information provided above is correct. If fingerprints are not provided to the Department by the next business day, the child MAY BE removed from your care. A fingerprint check is required by FL statutes for any adult persons over 18 who reside in the home where a dependent child is placed. This is to safeguard the child in that he/she will not be placed with a sexual predator/habitual criminal or any other charges that may indicate a potential risk to the child.
Results/Follow-up: Date Fingerprints Completed: / Date Results Received:
Date Requestor Advised of Results: / 0 Child may be placed
0 No Placement / Criminal History Indicates Risk
0 CPI needs to investigate further / Record found