Criminal Offender Record Information (Cori) Personal Request Form Page 2
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4Personal CORI Request Authorization
I hereby swear, under the penalties of perjury, that the information I have provided above is true to the best of my
knowledge and belief.
Signature of individual named in criminal record
Date
Authentication of Signature By Notary Public or Correctional Facility
On this ____ day of ___________, 20__, before me, the undersigned notary public, personally appeared
________________________ (name of document signer), proved to me through satisfactory evidence of
identification, which were _______________________, to be the person whose name is signed on the preceding or
attached document, and acknowledged to me that (he) (she) signed it voluntarily for its stated purpose.
Notary Public
Correctional Facility Official (give rank and title)
My Commission Expires
Correctional Facility Address and Phone
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