utah department of health criminal background screening authorization form

Prints will remain active for 60 days to allow for re-employment in a licensed setting. \ltrch\fcs0 \insrsid7565795 \chftnsep }{\rtlch\fcs1 \af5 \ltrch\fcs0 \insrsid7565795 \lsdsemihidden1 \lsdunhideused1 \lsdlocked0 HTML Variable;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Normal Table;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 annotation subject;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 No List; No hard copies of clearances will be required of programs, as all clearance information will be maintained in the DACS program. \par \tab \hich\af5\dbch\af31505\loch\f5 (a) Signs a criminal background screening authorization form which must be available for review by the department; and \lsdsemihidden1 \lsdunhideused1 \lsdlocked0 index 3;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 index 4;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 index 5;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 index 6; 1-800-897-LINK(5465). Code R432-35-5 - Covered Contractor - DACS Process; Utah Admin. \red255\green0\blue255;\red255\green0\blue0;\red255\green255\blue0;\red255\green255\blue255;\red0\green0\blue128;\red0\green128\blue128;\red0\green128\blue0;\red128\green0\blue128;\red128\green0\blue0;\red128\green128\blue0;\red128\green128\blue128; 0f88d94fbc52ae4264d1c910d24a45db3462247fa791715fd71f989e19e0364cd3f51652d73760ae8fa8c9ffb3c330cc9e4fc17faf2ce545046e37944c69e462 Providing your fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application. First Name Last Name. b48cc799fc0d91f134462b381daafb4a492472d591f0564cc0a1911e76ea5678ba4e4ed9223becacd7d5c16656590592e5782d2cc6e1a04a66e856bb3cc02bd4 Sources for Background Review. \lsdpriority51 \lsdlocked0 List Table 6 Colorful Accent 3;\lsdpriority52 \lsdlocked0 List Table 7 Colorful Accent 3;\lsdpriority46 \lsdlocked0 List Table 1 Light Accent 4;\lsdpriority47 \lsdlocked0 List Table 2 Accent 4; This action is part . Section R432-35-4 - Covered Provider - DACS Process (1) Covered providers shall enter required information into DACS to initiate a clearance for each covered individual prior to issuance of a provisional license, license renewal or engagement as a covered individual. Child Abuse/Neglect 1-800-897-LINK(5465), Abuse/Neglect of Seniors and Adults with Disabilities. To challenge State of Utah criminal arrests and disposition data please complete the required application and submit to the Utah Bureau of Criminal Identification. Missing or Incorrect State (Non-Federal) Information. {\fbimajor\f31541\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\fbimajor\f31542\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\fbimajor\f31543\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);} Applicants/licensees are responsible for the screening costs and should be aware that fees vary by service provider. \par \tab \hich\af5\dbch\af31505\loch\f5 (c) view medical or financial records. Before a determination is made, I understand that I will be afforded a reasonable amount of time to challenge the completeness and accuracy of the record through the procedures established by the Department of Human Services, Office of Licensing as well as contacting the Utah Bureau of Criminal Identification (Utah Criminal History Results), the State Identification Bureau (SIB) associated with any results that are outside of Utah, or the Federal Bureau of Investigation (Nationwide Criminal History Response Information). Utah Admin. Screening Applications. ffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffff Background Screening. Sec. \par \tab \hich\af5\dbch\af31505\loch\f5 (b) is not a covered provider; and 738c1dabfb8210cbaea764ce99604be97d41bc01224e93ccc899154da5d03149c02f1b1741f0b7659bd3e7de8051d7aa47f8c246c2de40d4417e86a965c6fb68 b01d583deee5f99824e290b4ba3f364eac4a430883b3c092d4eca8f946c916422ecab927f52ea42b89a1cd59c254f919b0e85e6535d135a8de20f20b8c12c3b0 \par \tab \hich\af5\dbch\af31505\loch\f5 (4) A covered contractor may provisionally supply a covered individual to a covered provider while clearance is pendin\hich\af5\dbch\af31505\loch\f5 g. Covered Provider - Direct Access Clearance System Process. {\fdbmajor\f31525\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\fdbmajor\f31526\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\fhimajor\f31528\fbidi \fswiss\fcharset238\fprq2 Calibri Light CE;} Mail the Authorization form, fingerprint card, and certified check or money order (personal checks are not accepted) for $65.00 made \par \par \tab \hich\af5\dbch\af31505\loch\f5 (15) "Resident" means an individual who receives health care services from one of the following\hich\af5\dbch\af31505\loch\f5 covered providers: Payment for both the license application fee and the FBI/BCI fingerprint fee of $28.25 ($13.25 FBI/$15 BCI) must be made by credit card during the online license application process. Please direct inquiries about fingerprinting, Utah criminal records (including expungement or correction procedures) to: Utah Department of Public Safety, Bureau of Criminal Identification (BCI), 3888 West 5400 South In the interest of professionalism, public trust and safety for families and individuals, Utah code requires that all persons associated with a licensed facility (owner, director, governing body, employee, agent, provider, contractor or volunteer) who has or will have direct access to children and/or vulnerable adults must pass a criminal background screening. In the event that there is incorrect or missing Utah Criminal Data, please be prepared to provide certified copies from any arresting agency or court of appearance. Resources 211Utah - United Way Safe UT. \par \tab \hich\af5\dbch\af31505\loch\f5 (i) a nursing assistant; d0cf11e0a1b11ae1000000000000000000000000000000003e000300feff090006000000000000000000000001000000010000000000000000100000feffffff00000000feffffff0000000000000000ffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffff 0000000000005b436f6e74656e745f54797065735d2e786d6c504b01022d0014000600080000002100a5d6a7e7c0000000360100000b00000000000000000000 Please be aware if the fingerprint authorization form is requested, the applicant has to wait for the Office to send the form with the fingerprint authorization before they can be live scanned. {\fdbminor\f31566\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\fhiminor\f31568\fbidi \fswiss\fcharset238\fprq2 Calibri CE;}{\fhiminor\f31569\fbidi \fswiss\fcharset204\fprq2 Calibri Cyr;} 1-855-323-DCFS(3237) Obtaining Utah Criminal History Records. The Utah Department of Health and Human Services is now one agency. 000000300100005f72656c732f2e72656c73504b01022d00140006000800000021006b799616830000008a0000001c0000000000000000000000000019020000 Multi-Agency State Office Building used by Utah Department of Health (UDOH) to determine my eligibility for licensure as a medical cannabis product establishment owners or directors, or . \par }{\rtlch\fcs1 \ab\af5 \ltrch\fcs0 \b\expnd0\expndtw-3\insrsid14438297 \hich\af5\dbch\af31505\loch\f5 R432-35-9. \lsdpriority72 \lsdlocked0 Colorful List Accent 6;\lsdpriority73 \lsdlocked0 Colorful Grid Accent 6;\lsdqformat1 \lsdpriority19 \lsdlocked0 Subtle Emphasis;\lsdqformat1 \lsdpriority21 \lsdlocked0 Intense Emphasis; \lsdsemihidden1 \lsdunhideused1 \lsdlocked0 List Number 4;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 List Number 5;\lsdqformat1 \lsdpriority10 \lsdlocked0 Title;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 Closing; \lsdsemihidden1 \lsdunhideused1 \lsdlocked0 List Continue;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 List Continue 2;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 List Continue 3;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 List Continue 4; \par \par \tab \hich\af5\dbch\af31505\loch\f5 (1) Convictions or Pending Charges As a new employee of a DHS licensed agency or DHS contracted agency your background screening process will be fully automated in the Direct Access Clearance System (DACS). \par \tab \hich\af5\dbch\af31505\loch\f5 (ii) a disabled individual, as defined by department rule; \par }}{\*\aftncn \ltrpar \pard\plain \ltrpar\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0\pararsid14438297 \rtlch\fcs1 \af5\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\loch\af5\hich\af5\dbch\af31505\cgrid\langnp1033\langfenp1033 { National Suicide Prevention Lifeline 534. \par \tab \hich\af5\dbch\af31505\loch\f5 (iii) surrounding circumstances; Utah Domestic Violence 1-800-273-TALK(8255) For information on obtaining the Out of State Registry, visit this link on our website: https://dlbc.utah.gov/out-of-state-registries, Submit the fee of $37.25 per application in one of the following forms: Company check, cashiers check, or money order made payable to Department of Human Services. \par \tab \hich\af5\dbch\af31505\loch\f5 (c) federal criminal background databases available to the state; If the applicant already has a RapBack subscription in DACS, the system will allow the screening agent to link to that application without paying new fees. \lsdpriority47 \lsdlocked0 List Table 2 Accent 3;\lsdpriority48 \lsdlocked0 List Table 3 Accent 3;\lsdpriority49 \lsdlocked0 List Table 4 Accent 3;\lsdpriority50 \lsdlocked0 List Table 5 Dark Accent 3; 8376bf330efaaff23606569ea58fdc16605ecdebde7f010000ffff0300504b0304140006000800000021000dd1909fb60000001b010000270000007468656d65 \lsdsemihidden1 \lsdunhideused1 \lsdlocked0 List 4;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 List 5;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 List Bullet 2;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 List Bullet 3; ;}{\levelnumbers\'01;}\rtlch\fcs1 \af0 \ltrch\fcs0 \lsdpriority49 \lsdlocked0 List Table 4 Accent 1;\lsdpriority50 \lsdlocked0 List Table 5 Dark Accent 1;\lsdpriority51 \lsdlocked0 List Table 6 Colorful Accent 1;\lsdpriority52 \lsdlocked0 List Table 7 Colorful Accent 1; Headquarters Multi-Agency State Office Building 195 North 1950 West Salt Lake City, Ut 84116. If there are criminal or abuse/neglect history items to disclose, you are asked to do so in either an uploaded document via your screening agent or if you choose not to share details with them, you may submit directly to OL at cbsunit@utah.gov, please be sure to place the DACS application number and your name and dob on your email or we will not know whose application to link the disclosure to. \par \tab \hich\af5\dbch\af31505\loch\f5 (b) As required by Utah Code Subsection 26-21-204, if an individual or covered individual has a warrant for arrest or an arrest for any of the identified offenses in R43\hich\af5\dbch\af31505\loch\f5 provide personal demographics required; and iii. \par \tab \hich\af5\dbch\af31505\loch\f5 (b) juvenile court arrest, adjudication, and disposition records, as allowed under Section 78A-6-209; This screening requires a separate application (see below). \hres0\chhres0 }{\listlevel\levelnfc4\levelnfcn4\leveljc0\leveljcn0\levelfollow2\levelstartat1\levelspace0\levelindent0{\leveltext\'02\'03. \par \tab \hich\af5\dbch\af31505\loch\f5 (c) a hospice; I understand that my personal information including name, DOB, SSN and fingerprints will be used for the purpose of . Criminal Background Screening Published: Nov 30, 2022 Responsible Unit: Vice President for Human Resources 1. \lsdpriority50 \lsdlocked0 List Table 5 Dark Accent 2;\lsdpriority51 \lsdlocked0 List Table 6 Colorful Accent 2;\lsdpriority52 \lsdlocked0 List Table 7 Colorful Accent 2;\lsdpriority46 \lsdlocked0 List Table 1 Light Accent 3; \par \tab \hich\af5\dbch\af31505\loch\f5 (i) the type of offense; Bureau of Central Services. \par \tab \hich\af5\dbch\af31505\loch\f5 (a) As required by Utah Code Subsection 26-21-204(3), the Department ma\hich\af5\dbch\af31505\loch\f5 \lsdsemihidden1 \lsdunhideused1 \lsdlocked0 index 7;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 index 8;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 index 9;\lsdsemihidden1 \lsdlocked0 toc 1;\lsdsemihidden1 \lsdlocked0 toc 2; {\fhimajor\f31533\fbidi \fswiss\fcharset177\fprq2 Calibri Light (Hebrew);}{\fhimajor\f31534\fbidi \fswiss\fcharset178\fprq2 Calibri Light (Arabic);}{\fhimajor\f31535\fbidi \fswiss\fcharset186\fprq2 Calibri Light Baltic;} The FBI has determined that under Public Law 105-251 private entities can receive FBI criminal data. In the event that a new fingerprint based criminal offense is detected, OL will be alerted and will change the employment status to supervised only until the disposition is achieved. \par \tab \hich\af5\dbch\af31505\loch\f5 (iii) potential risk to patients or residents. Hotlines Abuse/Neglect of Seniors and Adults with Disabilities 1-800-371-7897 Child Abuse/Neglect 1-855-323-DCFS(3237) ere has been a failure to comply with the provisions of this chapter, or rules promulgated pursuant to this chapter, as follows: \par }{\rtlch\fcs1 \ab\af5 \ltrch\fcs0 \b\expnd0\expndtw-3\insrsid14438297 \hich\af5\dbch\af31505\loch\f5 R432-35-3. \rtlch\fcs1 \af5\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\loch\f5\hich\af5\dbch\af31505\cgrid\langnp1033\langfenp1033 \sbasedon0 \snext0 toc 8;}{\s29\ql \fi-720\li720\ri0\sl240\slmult0\nowidctlpar Headquarters The Department of Human Services, Office of Licensing will establish procedures to ensure removal of my fingerprints from applicable state and federal databases when I am no longer under their purview. Definitions. \par \tab \hich\af5\dbch\af31505\loch\f5 (c) name. {\*\pnseclvl7\pnlcrm\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl8\pnlcltr\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl9\pnlcrm\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}\pard\plain \ltrpar (a) As required by Utah Code Subsection 26-21-204, if an individual or covered individual has been convicted, has pleaded no contest, or is subject to a plea in abeyance or diversion agreement, for the following offenses, they may not have direct patient access: (i) any felony or class A conviction under Utah Code. The DPS must receive the authorization form with the "original" signature. \par \tab \hich\af5\dbch\af31505\loch\f5 (g) registries of nurse aids described in Title 42 Code of Federal Regulations Section 483.156; \par \tab \hich\af5\dbch\af31505\loch\f5 (a) an end stage renal disease facility; Background Check Request (BCR) (DCF-F-5296) English / Hmong / Spanish Barred Offenses - Regulated Child Care (DCF-P-5206) Child Care Background Check Attestation (DCF-F-5365) English / Spanish 3f2451eced0dae2c082e8761be9969bb979dc9136332de3168aa1a083ae995719ac16db8ec8e4052164e89d93b64b060828e6f37ed1567914b284d262452282e Contact information for each state is provided on the State Identification Bureau listing. 1-801-587-3000 exclude the individual from direct patient access if the adjudications refer to an act that, if committed by an adult, would be a felony or a misdemeanor. Call: (801) 538-4242 1-855-323-DCFS(3237) Crisis Line & Mobile Outreach Team In the interest of professionalism, public trust and safety for families and individuals, Utah code requires that all persons associated with a licensed facility (owner, director, governing body, employee, agent, provider, contractor or volunteer) who has or will have direct access to children and/or vulnerable adults must pass a criminal background screening. {\*\colorschememapping 3c3f786d6c2076657273696f6e3d22312e302220656e636f64696e673d225554462d3822207374616e64616c6f6e653d22796573223f3e0d0a3c613a636c724d \lsdpriority69 \lsdlocked0 Medium Grid 3 Accent 2;\lsdpriority70 \lsdlocked0 Dark List Accent 2;\lsdpriority71 \lsdlocked0 Colorful Shading Accent 2;\lsdpriority72 \lsdlocked0 Colorful List Accent 2;\lsdpriority73 \lsdlocked0 Colorful Grid Accent 2; }{\rtlch\fcs1 \af5 \ltrch\fcs0 \expnd0\expndtw-3\insrsid14438297 \leveljcn0\levelfollow2\levelstartat1\levelspace0\levelindent0{\leveltext\'03(\'04);}{\levelnumbers\'02;}\rtlch\fcs1 \af0 \ltrch\fcs0 \hres0\chhres0 }{\listlevel\levelnfc4\levelnfcn4\leveljc0\leveljcn0\levelfollow2\levelstartat1\levelspace0\levelindent0 \noqfpromote {\stylesheet{\ql \li0\ri0\nowidctlpar\wrapdefault\faauto\rin0\lin0\itap0 \rtlch\fcs1 \af5\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\loch\f5\hich\af5\dbch\af31505\cgrid\langnp1033\langfenp1033 \snext0 \sqformat \spriority0 Normal;} Covered Employer - Direct Access Clearance System Process. \par }{\rtlch\fcs1 \ab\af5 \ltrch\fcs0 \b\expnd0\expndtw-3\insrsid14438297 \hich\af5\dbch\af31505\loch\f5 R432-35-10. For federal Identity History Summary updates, the FBI must receive a request directly from the original arresting agency, from a court with control over the arrest data, or from another agency with control over the arrest data. Title: Microsoft Word - Policies and Procedures for Conducting Criminal Background Checks.docx In giving this authorization, I Choose which box in the top left applies to you: If you are a new applicant with Utah Foster Care, mark the first box, If you are already licensed as a DCFS Foster Parent, or are residing in an Office of Licensing licensed foster home, mark the second box and include the licensor name, If you are working with an agency other that Utah Foster Care or DCFS, mark the third box and include the name of the agency, Legibly complete sections 1-5, filling in every box. . \par \tab \hich\af5\dbch\af31505\loch\f5 (v) licensing and certification records of individuals licensed or certified by the Division of Occupational and Professional Licen\hich\af5\dbch\af31505\loch\f5 sing under Title 58, Occupations and Professions; and ed21842cecc22eb9e48f31d8249b3f22afaa5bdd5552c99e191c3061463074977eefd5afde7bf5de53d5ddcf5e26d4bbc05c1096f6fcfa9d9aefe174ce16248d \par \tab \hich\af5\dbch\af31505\loch\f5 (b) a long-term care hospital; ;}{\levelnumbers\'01;}\rtlch\fcs1 \af0 \ltrch\fcs0 \hres0\chhres0 }{\listlevel\levelnfc0\levelnfcn0\leveljc0\leveljcn0\levelfollow2\levelstartat1\levelspace0\levelindent0{\leveltext\'02\'02. \lsdpriority49 \lsdlocked0 Grid Table 4 Accent 2;\lsdpriority50 \lsdlocked0 Grid Table 5 Dark Accent 2;\lsdpriority51 \lsdlocked0 Grid Table 6 Colorful Accent 2;\lsdpriority52 \lsdlocked0 Grid Table 7 Colorful Accent 2; \qj \li0\ri0\sl240\slmult0\nowidctlpar\wrapdefault\hyphpar0\faauto\rin0\lin0\itap0 \rtlch\fcs1 \af5\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\loch\af5\hich\af5\dbch\af31505\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \ab\af5 \ltrch\fcs0 One-time Adoption Screening. \fs24\lang1033\langfe1033\loch\f5\hich\af5\dbch\af31505\cgrid\langnp1033\langfenp1033 \sbasedon0 \snext0 toc 5;}{\s26\ql \fi-720\li720\ri0\sl240\slmult0\nowidctlpar\tqr\tx9360\wrapdefault\hyphpar0\faauto\rin0\lin720\itap0 \rtlch\fcs1 \af5\afs24\alang1025 Before you get a background screening report about a prospective employee, disclose to the person that you intend to get the report and then get their written authorization allowing you to do that. \par }{\rtlch\fcs1 \ab\af5 \ltrch\fcs0 \b\expnd0\expndtw-3\insrsid14438297 \hich\af5\dbch\af31505\loch\f5 R432-35-8. 1-888-421-1100 Depending on the nature of your application, supplemental authorities . Additional Information: The requesting agency and/or the agency conducting the application investigation will provide you additional information pertinent to the specific circumstances of this application, which may include identification of other authorities, purposes, uses, and consequences of not providing requested information. 1cac24d91adc3d8d1797de195df3a708422c6cd795011744c0dd413db3e682c0655891c8caf8db294c79da356fa3740c65e388ae62945714339967709dca0b3a 195 North 1950 West \par \tab \hich\af5\dbch\af31505\loch\f5 (B) 76-5 Offenses Against the Person; \lsdsemihidden1 \lsdunhideused1 \lsdlocked0 List Bullet 4;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 List Bullet 5;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 List Number 2;\lsdsemihidden1 \lsdunhideused1 \lsdlocked0 List Number 3; \lsdpriority65 \lsdlocked0 Medium List 1;\lsdpriority66 \lsdlocked0 Medium List 2;\lsdpriority67 \lsdlocked0 Medium Grid 1;\lsdpriority68 \lsdlocked0 Medium Grid 2;\lsdpriority69 \lsdlocked0 Medium Grid 3;\lsdpriority70 \lsdlocked0 Dark List; Call: (801) 538-4242 \par \tab \hich\af5\dbch\af31505\loch\f5 (vi) administrative staff, including a manager or other administrator; licensing requirements The agency will keep it on file and make it available as needed by the Office of Licensing, If a screening is denied, you and/or your background screening agent will be notified in writing, along with appeal procedures. Receiving Results: Once the Office reviews this information a determination will be made per 62A-2-120 and emailed from the Office to the email address provided from the non-licensed entity on the Background Screening Application. \af5\afs24\alang1025 \ltrch\fcs0 \fs24\lang1033\langfe1033\loch\f5\hich\af5\dbch\af31505\cgrid\langnp1033\langfenp1033 \sbasedon0 \snext0 toc 7;}{\s28\ql \fi-720\li720\ri0\sl240\slmult0\nowidctlpar\tqr\tx9360\wrapdefault\hyphpar0\faauto\rin0\lin720\itap0 Background Screening Unit. }}{\*\pnseclvl2\pnucltr\pnstart1\pnindent720\pnhang {\pntxta . West virginia university football stadium photos . A face covering or mask is recommended for anyone being fingerprinted. 3198720e274a939cd08a54f980ae38a38f56e422a3a641c8bbd048f7757da0f19b017cc524bd62107bd5001996509affb3fd381a89672f1f165dfe514173d985 earance for a covered individual. Call: (801) 538-4242 \par \tab \hich\af5\dbch\af31505\loch\f5 (1) "Aged" means an individual who is 60 years of age or older. Salt Lake City, UT 84114-8280. If you submit your forms via email, the Department will contact you to take payment over the phone. \sbasedon0 \snext15 \slink16 endnote text;}{\*\cs16 \additive \rtlch\fcs1 \af5\afs20 \ltrch\fcs0 \f5\fs20 \sbasedon10 \slink15 \slocked \ssemihidden \styrsid14438297 Endnote Text Char;}{\*\cs17 \additive \rtlch\fcs1 \af0 \ltrch\fcs0 \super \sbasedon10

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