Form Sp 4-164a - Pennsylvania State Police Request For Criminal Record Check - Volunteer Only
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1SP 4-164A (7-2015)
PENNSYLVANIA STATE POLICE
REQUEST FOR CRIMINAL RECORD CHECK
VOLUNTEER ONLY
1-888-QUERYPA (1-888-783-7972)
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
https://epatch.state.pa.us
REQUESTER
NAME
AFTER COMPLETION MAIL TO:
ADDRESS
PENNSYLVANIA STATE POLICE
CENTRAL REPOSITORY – RCPU
CITY/STATE/
1800 ELMERTON AVENUE
ZIP CODE
HARRISBURG, PA 17110-9758
TELEPHONE NO.
(AREA CODE)
SUBJECT OF RECORD CHECK
(FIRST)
(MIDDLE)
(LAST)
MAIDEN NAME AND/OR ALIASES
SOCIAL SECURITY NUMBER
DATE OF BIRTH
SEX
RACE
(MM/DD/YYYY)
VOLUNTEER’S AGENCY/ORGANIZATION (MANDATORY)
TELEPHONE NUMBER
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.
By signing this form, I verify that I am submitting this request for criminal history record information in connection with my
status as an unpaid volunteer. I understand that the $8 fee is being waived because of my status as an unpaid volunteer.
REQUESTER SIGNATURE
( *Signature required for processing*)
DATE
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.
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