Missouri Department of Social Services Children’s Division PO Box 88 Jefferson City, MO 65103 CD.REQUESTFORFINGERPRINTBASEDBACKGROUNDCHECKS@DSS.MO.GOV
REQUEST FOR FINGERPRINT BASED BACKGROUND CHECK RESULTS
The purpose of this form is to request fingerprint results for an individual who was fingerprinted for the purpose of Foster Care Screening. This form is to be completed by the individual who was fingerprinted. Only the individual who was fingerprinted may obtain the fingerprint results. The individual who was fingerprinted may obtain the results, with a valid photo ID, at the Children’s Division county office where the requestor resides.
FIRST NAME	MI	LAST NAME
SSN	DOB
TCN	DATE PRINTED
TELEPHONE NUMBER	EMAIL ADDRESS (REQUIRED)
STREET ADDRESS
CITY	STATE	ZIP
CHILDREN’S DIVISION COUNTY OFFICE WHERE REQUESTOR RESIDES AND RESULTS WILL BE PICKED UP
The local Children’s Division office provided the requestor with a copy of their fingerprint results, this form is being submitted for tracking purposes ONLY: Circle one YES NO
SIGNATURE OF REQUESTOR	DATE
For Office Use Only
STAFF SIGNATURE	DATE REQUEST SENT TO COUNTY