Forms OCFS 4411 - 5200E

The New York State Office of Children and Family Services (OCFS) is responsible for overseeing various programs and services designed to support children, families, and individuals with disabilities. As part of this responsibility, the agency has developed a number of forms and applications to facilitate the administration of its programs. The following is a list of some of the forms commonly used by OCFS.

• OCFS-4411 - Potassium Iodide-KI Refusal-Opt-Out Form: Form for opting out of the Potassium Iodide program.
• OCFS-4415 - Re-entry Into Foster Care for Youth Age 18 and Over Eligibility Checklist: Checklist to determine eligibility for re-entry into foster care for individuals above the age of 18.
• OCFS-4430NYC - NYC Application for the Kinship Guardianship Assistance and Non-Recurring Guardianship Expenses Programs -KinGap: Application form for the Kinship Guardianship Assistance and Non-Recurring Guardianship Expenses Programs in NYC.
• OCFS-4431 - Kinship Guardianship Assistance and Nonrecurring Guardianship Expenses Agreement: Agreement form for the Kinship Guardianship Assistance and Non-Recurring Guardianship Expenses Program.
• OCFS-4432 - Kinship Guardianship Assistance and Non-Recurring Guardianship Expenses Amendment: Amendment form for the Kinship Guardianship Assistance and Non-Recurring Guardianship Expenses Program.
• OCFS-4433 - Kinship Guardianship Assistance Program Certification Form: Certification form for the Kinship Guardianship Assistance Program.
• OCFS-4435a - Kinship Guardianship Assistance Eligibility Checklist: Checklist to determine eligibility for the Kinship Guardianship Assistance Program.
• OCFS-4435b - Kinship Guardianship Assistance Eligibility Checklist Instructions: Instructions for completing the Kinship Guardianship Assistance Eligibility Checklist.
• OCFS-4435c - Affidavit of Relationship: Form for establishing legal relationship between the caregiver and the child in the Kinship Guardianship Assistance Program.
• OCFS-4436 - Incident Report for Child Day Care: Report form for incidents that occur in child day care facilities.
• OCFS-4437 - Kinship Guardianship Assistance and Non-Recurring Guardianship Expenses Agreement Successor Guardian Amendment: Amendment form for the successor guardian under the Kinship Guardianship Assistance and Non-Recurring Guardianship Expenses Program.
• OCFS-4438 - Domestic Violence Agency-Cover Page-Application Requirements for Approval of Proposed Certificate of Incorporation: Form for domestic violence agencies to apply for approval of proposed certificate of incorporation.
• OCFS-4441 - Quarterly Report: Report form for quarterly updates.
• OCFS-4441a - MWBE Monthly Report Form - Superstorm Sandy Grants Only: Report form for monthly updates on MWBE compliance for Superstorm Sandy grants only.
• OCFS-4442 - Request for Waiver Form: Form to request a waiver of certain requirements.
• OCFS-4529 - Telecommunications Service Request: Request form for telecommunications services.
• OCFS-4555 - Non-Discrimination - Non-Sectarian Compliance: Compliance form for non-discrimination and non-sectarian policies.
• OCFS-4584 - Application Form for Equipment Loan Fund for the Disabled (html): HTML version of the application form for the Equipment Loan Fund for the Disabled.
• OCFS-4584 - Application Form for Equipment Loan Fund for the Disabled: Application form for the Equipment Loan Fund for the Disabled.
• OCFS-4599 - Report of Legal Blindness-Request for Information: Request form for information related to legal blindness.
• OCFS-4615 - Supervision and Treatment Services for Juveniles Program: Program application form for Supervision and Treatment Services for Juveniles.
• OCFS-4622 - Notice to Expunge Associated Fingerprints: Notification form for expunging associated fingerprints.
• OCFS-4627 - Request for Forms and Publications: Request form for OCFS forms and publications.
• OCFS-4629 - Project Staffing Plan: Plan form for project staffing.
• OCFS-4631 - MWBE Utilization Plan: Plan form for Minority and Women-Owned Business Enterprises (MWBE) utilization.
• OCFS-4639 - Domestic Violence New Application: Application form for domestic violence services.
• OCFS-4641 - Domestic Violence Recertification: Recertification form for domestic violence services.
• OCFS-4659. Waiver for Submission of a Duplicate Fingerprint Card
• OCFS-4665 - Detention Services Systems User Access Request Form: Request form for user access to detention services systems.
• OCFS-4680 - Notice to NYS OCFS of Foster Home Transfer Between Authorized Agencies: Notification form for foster home transfer between authorized agencies.
• OCFS-4685 - Kinship Guardianship Assistance Eligibility Checklist: Checklist to determine eligibility for the Kinship Guardianship Assistance Program.
• OCFS-4686 - Form and Publication Approval Form: Approval form for OCFS forms and publications.
• OCFS-4690 - Adoptive Placement Fee Disclosure Form: Form for disclosing adoptive placement fees.
• OCFS-4707 - Youth Advisory Board Member Application: Application form for youth advisory board membership.
• OCFS-4714 - National Electronic Interstate Compact Enterprise (NEICE) Non-Disclosure Agreement: Non-disclosure agreement for NEICE.
• OCFS-4715 - Confidentiality Non-Disclosure Agreement: Non-disclosure agreement for confidentiality.
• OCFS-4722 - Voluntary Agency Licensing - Application for OCFS Approval of Certificate of Incorporation: Application form for voluntary agency licensing and approval of certificate of incorporation by OCFS.
• OCFS-4732 - Information on Foster Placements of Children Adopted from Other Countries: Information form for foster placements of children adopted from other countries.
• OCFS-4743 - Foster Parent Request for the Release of the Social Security Number of a Child in Foster Care for Income Tax Purposes: Request form for releasing the social security number of a child in foster care for income tax purposes.
• OCFS-4743a - Foster Parent Request for the Release of the Social Security Number of a Child in Foster Care for Purposes of Section 8 Rental Assistance: Request form for releasing the social security number of a child in foster care for purposes of Section 8 rental assistance.
• OCFS-4744 - Adoption Subsidy Direct Deposit/Debit Card Authorization Form: Authorization form for direct deposit/debit card for adoption subsidy.
• OCFS-4751 - Volunteer Application-Registration: Application form for volunteering with OCFS.
• OCFS-4773 - Child Care Eligibility Re-determination Coming Due (Sample Only): Sample notification form for eligibility re-determination of child care services.
• OCFS-4777 - Federal Foster Care Candidacy Determination Form: Form for determining federal candidacy for foster care.
• OCFS-4821 - CMS User Authorization: User authorization form for CMS.
• OCFS-4830 - Detention Services Unusual Incident Report: Report form for unusual incidents in detention services.
• OCFS-4836 - Application Checklist for Runaway and Homeless Youth Crisis Services Program or Transitional Independent Living Support Program: Checklist for applying to the Runaway and Homeless Youth Crisis Services Program or Transitional Independent Living Support Program.
• OCFS-4836a - Application for OCFS Approval of Certificate of Incorporation to Provide Residential Runaway and Homeless Youth Services: Application form for OCFS approval of certificate of incorporation to provide residential runaway and homeless youth services.
• OCFS-4879 - Child Day Care Program Training Tracking Chart: Chart for tracking training in child day care programs.
• OCFS-4880 - Individual Training Tracking Form: Form for tracking individual training.
• OCFS-4887 - Request for Waiver: Form to request a waiver of certain requirements.
• OCFS-4895 - Vendor and Contract Contact Update Form: Form for updating vendor and contract contacts.
• OCFS-4922 - Transition Plan: Plan form for transition to a new program or service.
• OCFS-4924 - DJJOY Transition Plan: Plan form for transition to DJJOY services.
• OCFS-4930 - Request for NYS Fingerprinting Services - Information Form: Information form for requesting NYS fingerprinting services.
• OCFS-4930-1 - Guidelines for Fingerprinting: Guidelines for fingerprinting requirements.
• OCFS-4930ASFA - Request for NYS Fingerprinting Services - Information Form: Information form for requesting NYS fingerprinting services for ASFA cases.
• OCFS-4930MTR - Request for NYS Fingerprinting Services - Information Form: Information form for requesting NYS fingerprinting services for Mental Health Treatment records.
• OCFS-4934 - Advisory Board Application: Application form for advisory board membership.
• OCFS-4937 - Hague International Adoption Request Form: Request form for Hague international adoption.
• OCFS-4940 - Designation of Person in Parental Relationship: Form for designating a person in parental relationship.
• OCFS-4980 - Location Preference Sheet: Sheet for indicating location preferences.
• OCFS-4992 - Qualified Residential Treatment Program (QRTP) Attestation Form: Attestation form for the QRTP program.
• OCFS-5003 - Individual Program Application - Program Summary-Program Components: Application form for individual programs with program summary and components.
• OCFS-5003A - Coding Document for OCFS-5003 Program Summary-Program Components: Coding document for the OCFS-5003 program.
• OCFS-5004 - Request for Amendment and Instructions: Request form for amendment with instructions.
• OCFS-5014 - Parental Consent Form: Form for obtaining parental consent.
• OCFS-5017 - Child in Foster Care Sample Notification Letter: Sample notification letter for children in foster care.
• OCFS-5018 - Local Transportation Agreement for Students in Foster Care: Agreement form for local transportation services for students in foster care.
• OCFS-5019 - Individual Transportation Plan for Students in Foster Care: Plan form for individual transportation services for students in foster care.
• OCFS-5023 - Authorization for Release of Information for Foster Boarding Home Certification or Approval Only: Authorization form for release of information for foster boarding home certification or approval only.
• OCFS-5033 - Language Services Tracking Form for In-Person Encounters with Limited English Proficient Persons: Tracking form for in-person encounters with limited English proficient persons.
• OCFS-5050 - Checklist for Caseworkers for ICPC Home Study Requests: Checklist for caseworkers for ICPC home study requests.
• OCFS-5050a - OCFS-5050 Cover Sheet: Cover sheet for the OCFS-5050 form.
• OCFS-5050b - Certification of Title IV-E Eligibility for Interstate Placements of New York Children: Certification form for Title IV-E eligibility for interstate placements of New York children.
• OCFS-5050c - Financial-Medical Plan: Plan form for financial and medical aspects of interstate placements.
• OCFS-5050d - Detailed Child Summary: Summary form for detailed child information.
• OCFS-5050e - Signed Statement of Sending Agency Case Manager: Statement form for sending agency case manager signature.
• OCFS-5050f - Regulation 7 - Combined Form: A combined form for regulations related to child day care centers and group family daycare homes.
• OCFS-5050g - Residential Placements Checklist for Caseworkers: A checklist used by caseworkers while placing children in residential care facilities.
• OCFS-5050h - Checklist for Private/Independent Adoption Requests: A checklist used for private or independent adoption requests to ensure all requirements are met.
• OCFS-5050i - Residential Placements Checklist for School Districts: A checklist used by school districts while placing children in residential care facilities.
• OCFS-5050j - Residential Placements Checklist for Parents/Guardians: A checklist used by parents or guardians while placing their children in residential care facilities.
• OCFS-5052 - ICPC Quarterly Supervision Report Form: A form used to report quarterly supervision of children placed out of state.
• OCFS-5107 - FFPSA of 2018 Out of State Child Abuse Register Check Letter: A letter requesting an out-of-state child abuse register check as per the Family First Prevention Services Act (FFPSA) of 2018.
• OCFS-5108 - Family First Prevention Services Act - Out of State Child Abuse Register Check: A form used to conduct an out-of-state child abuse register check as per the FFPSA of 2018.
• OCFS-5109 - Family First Prevention Services Act - Applicant Currently Living Outside New York State: A form used for individuals living outside New York State who wish to be foster or adoptive parents as per the FFPSA of 2018.
• OCFS-5183A - Self Assessment: A self-assessment form for those interested in becoming foster or adoptive parents.
• OCFS-5183B - Foster-Adoptive Parent Application: An application form for those interested in becoming foster or adoptive parents.
• OCFS-5183C - Family Adoption Registry Information (Formerly Application To Adopt): An information form for families interested in adoption.
• OCFS-5183D - Foster-Adoptive Applicant Medical Report: A medical report required for those applying to become foster or adoptive parents.
• OCFS-5183E - Safety Review Form: A form used to review the safety of a home for foster or adoptive care.
• OCFS-5183F - Household Composition and Relationships Form: A form that gathers information about household composition and relationships for foster or adoptive care applications.
• OCFS-5183G - Sample Genogram Template: A template for creating a genogram, which is a visual representation of family relationships.
• OCFS-5183H - Personal References: A form used to collect personal references for those applying to become foster or adoptive parents.
• OCFS-5183I - Resource Characteristics: A form used to identify the characteristics of the resources available for foster or adoptive care.
• OCFS-5183J - Foster Parent Agreement With Authorized Agency: An agreement between a foster parent and an authorized agency outlining their responsibilities.
• OCFS-5183K - Final Assessment-Determination: A final assessment-determination form for foster or adoptive care applications.
• OCFS-5183L - Annual Reauthorization Assessment and Determination: An annual reauthorization assessment-determination form for foster or adoptive care.
• OCFS-5184 - Foster Care Placement Verification Form: A form used to verify the placement of a child in foster care.
• OCFS-5200A - Self Assessment - Adoption Only: A self-assessment form for those interested in adoption only.
• OCFS-5200B - Adoptive Parent Application - Adoption Only: An application form for those interested in adoption only.
• OCFS-5200C - Family Adoption Registry Information - Adoption Only: An information form for families interested in adoption only.
• OCFS-5200D - Adoptive Applicant Medical Report - Adoption Only: A medical report required for those applying to adopt only.
• OCFS-5200E - Safety Review Form - Adoption Only: A form used to review the safety of a home for adoption only.

The forms listed above provide just a small snapshot of the many forms and applications that may be required or used by OCFS. By familiarizing themselves with these forms, individuals and organizations can ensure that they are in compliance with applicable laws and regulations, and can help ensure that the programs and services provided by OCFS are administered fairly, efficiently, and effectively. Whether you are a caregiver, service provider, or other individual working with OCFS, understanding these forms can help you fulfill your obligations and responsibilities under the agency's various programs.