Centers for Medicare & Medicaid Services AFFIDAVIT OF PERSON COLLECTING FINGERPRINTS 07/2014 ____________________________________________________________ Centers for Medicare & Medicaid Services require applicants to submit a fingerprint card to Accurate Biometrics for processing. This card will be used by Accurate Biometrics to submit the provider applicant’s fingerprints to the FBI to check their criminal history. • VIEW APPLICANT IDENTIFICATION & CONFIRM FINGERPRINT CARD IS COMPLETED WITH ALL REQUIRED PERSONAL INFORMATION • FBI REQUIRES THE USE OF THE FD258 PRINT CARD FOR COLLECTING PRINTS • FINGERPRINT APPLICANT & COMPLETE INFORMATION BELOW THIS IS A SWORN AFFIDAVIT of the person rolling fingerprints and signing the card: I SWEAR OR AFFIRM, UNDER PENALTY OF PERJURY, that I have personally observed the applicant sign the fingerprint card. I signed the FBI card, rolled the fingerprints of the applicant and personally reviewed the completed print card information for ___________________________________ by viewing a: Applicant’s Name Driver’s license #___________________________ State ________ Other: _______________________________________________ ________________________________________________________________________ Print or Type Name of Fingerprint Tech/Law Enforcement Agent Date Original Signature of Fingerprint Tech/Law Enforcement Agent Daytime Phone Number Agency or Business Name Mailing Address
4
Embed
Fingerprint Card Instructions PA Rev 061113 (2) · fd-258 (rev.12-10-07) leave blank applicant type or print all information in black fbi leave blank last name nam first name middle
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Centers for Medicare & Medicaid Services AFFIDAVIT OF PERSON COLLECTING FINGERPRINTS
07/2014
____________________________________________________________ Centers for Medicare & Medicaid Services require applicants to submit a fingerprint card to Accurate Biometrics for processing. This card will be used by Accurate Biometrics to submit the provider applicant’s fingerprints to the FBI to check their criminal history.
• VIEW APPLICANT IDENTIFICATION & CONFIRM FINGERPRINT CARD IS COMPLETED WITH ALL REQUIRED PERSONAL INFORMATION
• FBI REQUIRES THE USE OF THE FD-‐258 PRINT CARD FOR COLLECTING PRINTS • FINGERPRINT APPLICANT & COMPLETE INFORMATION BELOW
THIS IS A SWORN AFFIDAVIT of the person rolling fingerprints and signing the card:
I SWEAR OR AFFIRM, UNDER PENALTY OF PERJURY, that I have personally observed the applicant sign the fingerprint card. I signed the FBI card, rolled the fingerprints of the applicant and personally reviewed the completed print card information for ___________________________________ by viewing a: Applicant’s Name
Driver’s license #___________________________ State ________