Form Cclu 2 - Criminal History Record Information Authorization

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State of New Hampshire
CCLU 2
Criminal Records Unit
Department of Safety
DIVISION OF STATE POLICE
33 Hazen Drive, Concord, NH 03305
NEW HAMPSHIRE HEALTH AND HUMAN SERVICES CRIMINAL HISTORY RECORD INFORMATION AUTHORIZATION
CHILD DAY CARE NH RSA 170-E:7 II
CHILD CARE INSTITUTIONS RSA 170-E:29-a:II
INSTRUCTIONS
NH RSA 106-B:14 and Administrative Rule Saf-C 5700 authorizes the dissemination of NH Criminal History Record Information (CHRI) for
non-criminal justice purposes. In NH, all CHRI is confidential and released only upon the knowledge and permission of the individual of whom
the request is made. Both Section I and Section II must be completed. All requests by mail must have both sections completed and Section II
notarized.
SECTION I
SECTION II
NAME: _______________________________________________
I hereby authorize the release of my criminal record conviction(s), if
Last
First
MI
any, to the following individual:
ADDRESS: ____________________________________________
Mychelle Brown/DHHS, Child Care Licensing Unit
STREET
CITY
STATE
ZIP CODE
129 Pleasant Street, Concord, NH 03301
ALL previous last names: _________________________________
Your Signature: _____________________________Date:_______
DOB: _________ Hair Color:_________ Eye Color:_____ Sex:___
Driver’s License #: ____________________________State:______
Notary Signature: _______________________________________
(AFFIX Seal)
(comm. exp.)
My signature below certifies I am the individual listed above and the
information provided is true.
Signature: _________________________________Date:________
Signed under penalty of unsworn falsification pursuant to RSA 641:3
RECORD CHALLENGE
Saf-C 5703.12 Procedure for Correcting a CHRI (a) Persons or their attorneys desiring access to their CHRI for the purpose of challenge or correction shall appear at the
central repository. (b) A copy shall be provided to a person if after review he/she indicates he/she needs the copy to pursue the challenge. (c) Any person making a challenge
shall identify that portion of his/her CHRI which he/she believes to be inaccurate or incorrect, and shall also give a correct version of his/her record with an explanation of the
reason that he/she believes his/her version to be correct. (d) The director shall take the following actions within 30 days of receipt of challenge: (1) Review the records and
contact the law enforcement agency or court which submitted the record to compare the information to determine whether the challenge is valid; (2) If the challenge is valid,
which means there is a discrepancy between the information submitted and the information maintained by the law enforcement agency or court, the record shall be corrected
and the person and appropriate CJAs shall be notified; and (3) If the challenge is invalid, the person shall be informed and advised of the right to appeal pursuant to RSA 541.
(e) When a record has been corrected, the division shall notify all non-criminal justice agencies, to whom the data has been disseminated in the last year, of the correction.(f)
The person shall be entitled to review the information that records the facts, dates, and results of each formal stage of the criminal justice process through which he passes, to
ensure that all such steps are completely and accurately recorded.
WARNING: The Division of State Police is the Criminal Record Repository for the State of New Hampshire. The record you have received is based only on what
has been reported to the Repository and may not be a complete Criminal History Record of the named individual.
FEES
Child Care Program: _____________________________________
NH STATE ONLY BACKGROUND CHECK $7.50
License #: ___________________________
Please include:
Payment payable to: State of NH – Criminal Records
Prepaid Account (if applicable): ____________________________
This notarized form with original signatures.
______________________________________________________
Mail to:
Program Physical Address (Street, City, State, Zip)
NH State Police, Criminal Record Unit
______________________________________________________
33 Hazen Drive
Program Mailing Address (Street or PO Box, City, State, Zip)
Concord, NH 03301
Effective 02/20/15
r:\program support\licensing\ccl\group\bccldocs\2015 chri forms\original word docs do not touch!\crhi state only and instructions.docx

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