Non-KORA Agency Records Request Form


 
Submission Date
Select Date
REQUESTOR INFORMATION
Name*
Position
Address*
City*
State*
Zip Code*
Work Phone*
Work FAX
Work E-mail*


REQUEST INFORMATION

Reason for Request

Additional Comments


RECORD INFORMATION

Please provide the following information on the person whose Kansas DCF case history is being requested.

Last Name*
First Name*
Maiden Name* ('N/A' if not applicable)
Date Of Birth*
Race*
Sex*
SSN*
Relationship to the Requestor*

File Uploads
*File size should be less than 50MB.
*Allowed file types: .doc;.docx;.pdf;.txt;.xlsx only.
*Do not use special characters(like #,$,%,@,*,/,..)in the file name.

'Photo ID' Copy*

'Release Of Information' Form*

Other File(s)


I hereby certify that I will not:
(A)
use any list of names or addresses contained in or derived from the records or information for the purpose of selling or offering for sale any property or service to any person listed or to any person who resides at any address listed; or
(B) sell,give, or otherwise make available to any person any list of names or addresses contained in or derived from the records or information for the purpose of allowing that person to sell or offer for sale any property or service to any person listed or to any person who resides at any address listed. K.S.A. 45-220(c)(2).


Signature*