This form is to be completed by all providers, household members, substitutes, volunteers, licensees, directors, teachers, assistant teachers and all support staff, age 19 and older, at initial licensing AND whenever there have been changes in staff or household composition AND whenever an application is submitted.

This statement MUST include all law enforcement contacts regardless of prosecution. List details, dates and county of disposition (i.e., parole, probation, incarceration, fine, community service, etc.) to the date this document is signedLaw enforcement records may be obtained and reviewed to determine the accuracy of this statement.

For each statement, if you have had NO law enforcement contacts, write "NONE"

Nebrasks DHHS
301 Centennial Mall South, Lincoln, Nebraska 68509-5026
Nebraska Department of Health & Human Services
P.O. Box 95026, Lincoln, Nebraska 68509-5026
Main Switchboard: 402-471-3121

Questions or concerns about DHHS: DHHS.Helpline@nebraska.gov
402-471-6035 OR 1-800-254-4202