Early Intervention Program Guidance on Early Intervention Program Records

Instructions for Completing the State Central Register Database Check Form LDSS-3370 Rev. 1/02

- It is



- The three-digit agency code should be placed in the top left-hand box, followed by the Resource I.D. (RID) in the next box to the right. (Contact the licensing agency if there are any questions about these.)
<-Clearance Category letter code (see back of Form LDSS-3370) should be placed in the middle box.
<-Phone number (with area code) enables the SCR to contact the agency liaison if this becomes necessary.

<-Agency Name: Please use full name, no abbreviations.
<-Agency Liaison is the contact person at the inquiring agency. (The SCR response will be addressed to the liaison.) <The liaison cannot be the applicant or a relative of the applicant.
-Agency Address:


<- ALL <-, <-Applicant's name. If there is more than one applicant place the additional name(s) on the lines below the maiden name line.
<-maiden names, previous married names, or aliases by which the applicant is or has been known. Use additional lines if there is more than one maiden/married/alias name to be listed.
<-Names of all other household members. (Attach an additional page if needed.)
NONE <- <-relationship to the applicant, of each person listed. (Spouse, son, daughter, mother, father, friend, etc.)
<-Sex M/F column: fill in either M (Male) or< F <-Date Of Birth column: fill in complete date of birth (mm/dd/yy) for everyone listed on the form.

The information required varies depending on the particular category:
<-Adoption,Foster Care and Family Day Care (see back of form for categories), provide addresses for the applicant Attach supplemental pages if necessary, but do not use another LDSS-3370 form to list this additional information. Be sure to associate address histories with particular individuals (i.e. indicate which addresses are for which household members). <
-<-. Include street name and city/town/village. Also include street number and apartment number<. Post Office box numbers are not acceptable.<-current address. The previous address should be listed on the second line downward, and so on back to January 1973 or the applicant's 18th birthday. Staple the attached supplemental page to the form if more space is needed, but do not use another copy of the LDSS-3370 for this additional information.

Signatures required depend upon the particular category:
<-Adoption, Foster Care and< Family Day Care <- <-Mary Smith should not sign Mary Ann Smith. Victoria Smith should not sign Vicki.
<- <-

If you have any questions concerning these instructions, call (518) 474-5297.
Forms may be ordered by writing:
NYS Family Assistance
Bureau of Forms & Print Management
PO Box 1990
Albany, NY 12201



Additional Page for Other Household Members

Additional Page for Address History of Household Members