Records Request for CYFAP

Date

MonthDayYear
Date
Hour Minutes
Records Request

Children, Youth, Families and Adult Protection
This form is for requesting Children, Youth and Families Child Abuse/Neglect Records located in Jefferson County only.

Parent/Legal custodian or guardian requests:
- Proof of Identity (Notarized copy of valid State ID or Driver's License)
- Custodial/Guardianship documnetation (If not parent)
  - Fee Statement: There is a charge $1.25 per page for copies of records. You will receive an estimate of amount of pages and the cost for your approval before we proceed. Payment by mail may be made by check or money order payable to the Jefferson County Treasurer. If you wish to come into the office to make a payment, then cash, debit or credit card be used. Currently, we have no means of accepting online payments. Please do not make a payment until you have been instructed.
CFIPRE Requests:
- Court order of appointment AND
- Relase of information from all parents, custodians, legal guardians involved
  - Fee Statement: the charge for records will be determined by the County Attorney's Office. Please state in your request if cost approval is needed prior to prepartion of records.
Attorney or attorney representative, investigator ot therapist
- Release of information from parent (if requesting for juvenille records)
- Release of information from self (if requesting adults records)
  - Fee Statement: the charge for records will be determined by the County Attorney's Office. Please state in your request if cost approval is needed prior to preperation of records.
Release of Information

If you are not the parent or legal guardian of the child(ren) you wish records for, you will need to provide a release of information from the parent or legal guardian and a notarized copy of those parents or guardians current identification. If you are a legal guardian of the child(ren) you will need to provide guardianship documentation from the court. If you are a CFI, you will need to provide your court appointment. If you are an Attorney or Attorney representative, please provide a release of information.

Please note that it can take 5 weeks or longer to complete a request. When your request is complete you will be notified by email that your records are ready. The email will include instructions on how to pay for and obtain the records.

Records Request
Requestor Name*

First NameLast Name
I, First Name* Last Name* , (Relationship to the information requested)* , on this date Date* , hereby request copies of Child abuse/neglect reports from the Jefferson County Department of Human Services as follows:
Any/all releasable recordsName a specific caseworker, incident, or timeframe - provide details here :
Choose only the Specific records you need as selecting the Any/All option can greatly increase the cost to you.
This information involves (Include yourself):*
If possible, I would like the reports by date (See below):
My preferred method of contact is:*

EmailPhone
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
If you are requesting your own or immediate family information you do not need to submit a Release of Information. If you do need to complete a Release of Information for CYF, please use the following link:

Release of Information
I have included the following documentation:*

Proof of identity (Notarized copy of valid State ID or Driver’s License) - Do not include proof of identity if you are paying in person as proof of identity is required at that time.Release of informationCourt order (if applicable)Other (specify)
Upload the above documents here

Reminder: Do not include proof of identity if you are paying in person as proof of identity is required at that time.
Cancelof
It can take up to 5 weeks or longer to complete a request.

There is a charge $1.25 per page for copies of records. You will receive an estimate of amount of pages and the cost for your approval before we proceed.

When completed the reports will be emailed to you.
Signature*

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