Form Sp 4-164 - Pennsylvania State Police Request For Criminal Record Check
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1PENNSYLVANIA STATE POLICE
SP 4-164 (7-2015)
REQUEST FOR CRIMINAL RECORD CHECK
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 – 164
1800 ELMERTON AVENUE
CITY/STATE/
HARRISBURG, PA 17110-9758
ZIP CODE
DO NOT SEND CASH OR PERSONAL
TELEPHONE NO.
CHECK
(AREA CODE)
CHECK ONE BLOCK
INDIVIDUAL/NONCRIMINAL JUSTICE AGENCY – ENCLOSE
A CERTIFIED CHECK/MONEY ORDER IN THE AMOUNT OF
$8.00, PAYABLE TO:
“COMMONWEALTH OF PENNSYLVANIA”
THE FEE IS NONREFUNDABLE
NOTARIZED INDIVIDUAL/NONCRIMINAL JUSTICE AGENCY –
ENCLOSE A CERTIFIED CHECK/MONEY ORDER IN THE
AMOUNT OF $13.00, PAYABLE TO:
“COMMONWEALTH OF PENNSYLVANIA”
THE FEE IS NONREFUNDABLE
FEE EXEMPT-NONCRIMINAL JUSTICE AGENCY – NO FEE
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 - $8.00. NOTARIZED FEE REQUESTS - $13.00.
***MAKE ALL MONEY ORDERS PAYABLE TO: COMMONWEALTH OF PENNSYLVANIA ***
REASON FOR REQUEST
◄◄◄◄◄◄CHECK THE BOX THAT MOST APPLIES TO THE PURPOSE OF THIS REQUEST►►►►►►
INTERNATIONAL ADOPTION -
INTERNATIONAL ADOPTION MUST BE NOTARIZED AND MAILED IN. ($13.00 FOR REQUEST)
ADOPTION (DOMESTIC)
EMPLOYMENT
VISA
OTHER
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
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