Form Sp 4-164 - Pennsylvania State Police Request For Criminal Record Check
ADVERTISEMENT
1PENNSYLVANIA STATE POLICE
SP 4-164 (2-2013)
REQUEST FOR CRIMINAL RECORD CHECK
This form is to be completed in ink by the requester – (information will be mailed to the
FOR CENTRAL REPOSITORY USE ONLY
requester only). If this form is not legible or not properly completed, it will be returned
CONTROL NUMBER
unprocessed to the requester. A response may take four weeks or longer.
TRY OUR WEBSITE FOR A QUICKER RESPONSE
AFTER COMPLETION MAIL TO:
https://epatch.state.pa.us
PENNSYLVANIA STATE POLICE
CENTRAL REPOSITORY – 164
NAME/
1800 ELMERTON AVENUE
REQUESTER
HARRISBURG, PA 17110-9758
ADDRESS
1-888-QUERYPA (1-888-783-7972)
DO NOT SEND CASH OR PERSONAL
CHECK
CITY/STATE/
ZIP CODE
CHECK ONE BLOCK
INDIVIDUAL/NONCRIMINAL JUSTICE AGENCY – ENCLOSE
A CERTIFIED CHECK/MONEY ORDER IN THE AMOUNT OF
$10.00, PAYABLE TO:
“COMMONWEALTH OF PENNSYLVANIA”
THE FEE IS NONREFUNDABLE
NOTARIZED INDIVIDUAL/NONCRIMINAL JUSTICE AGENCY –
ENCLOSE A CERTIFIED CHECK/MONEY ORDER IN THE
CONTACT TELEPHONE NUMBER (INCLUDING AREA CODE)
AMOUNT OF $15.00, PAYABLE TO:
“COMMONWEALTH OF PENNSYLVANIA”
THE FEE IS NONREFUNDABLE
-
-
FEE EXEMPT-NONCRIMINAL JUSTICE AGENCY – NO FEE
NAME/SUBJECT OF RECORD CHECK (FIRST)
(MIDDLE)
(LAST)
MAIDEN NAME AND/OR ALIASES
SOCIAL SECURITY NUMBER
DATE OF BIRTH
SEX
RACE
(MM/DD/YYYY)
The Pennsylvania State Police response will be based on the comparison of the data provided by the requester
against the information contained in the files of the Pennsylvania State Police Central Repository only
FEES FOR REQUESTS - $10.00. NOTARIZED FEE REQUESTS - $15.00.
***MAKE ALL MONEY ORDERS PAYABLE TO: COMMONWEALTH OF PENNSYLVANIA ***
◄◄◄◄◄◄CHECK BOX THAT MOST APPLIES TO THE PURPOSE OF THIS REQUEST►►►►►►
REASON FOR REQUEST
INTERNATIONAL ADOPTION -
INTERNATIONAL ADOPTION MUST BE NOTARIZED AND MAILED IN. ($15.00 FOR REQUEST)
ADOPTION (DOMESTIC)
EMPLOYMENT/SCREENING
PASSPORT
ATTORNEY
FOSTER CARE
PRIVATE INVESTIGATIONS
BANKING
HEALTHCARE
SOCIAL SERVICES
BAR ASSOCIATION
HOUSING
TENANT CHECK
CHURCH
INSURANCE LICENSE
VISA
CHILD CARE
MENTAL HEALTH
VOLUNTEER AMBULANCE/FIREFIGHTER
EDUCATION
NURSE AID TRAINING
VOLUNTEER
ELDER CARE
OTHER
_________________
EMERGENCY MANAGEMENT
ACCESS & REVIEW - (NOT FOR EMPLOYMENT PURPOSES.
MUST BE MAILED INTO THE CENTRAL
REPOSITORY WITH A COPY OF A VALID GOVERNMENT ISSUED PHOTO ID, SEE TERMS & CONDITIONS)
AVAILABLE ONLY TO SUBJECT OF RECORD OR LEGAL REPRESENTATIVE WITH LEGAL AFFIDAVIT AND REQUIRED COPY OF GOVERNMENT
.
PHOTO ID ATTACHED FOR THE PURPOSE OF REVIEWING YOUR CRIMINAL HISTORY
WARNING:
18 Pa.C.S. 4904(b) UNDER PENALTY OF LAW - MISIDENTIFICATION OR FALSE STATEMENTS OF IDENTITY TO OBTAIN CRIMINAL
HISTORY INFORMATION OF ANOTHER IS PUNISHABLE AS AUTHORIZED BY LAW.
Homeland Security is Everyone’s Responsibility - Pennsylvania Terrorism Tip Line 1-888-292-1919
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal