Request For Adult Criminal History Form Page 2
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Child molest (IC 35‐42‐4‐3);
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Child exploitation (IC 35‐42‐4‐4b);
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Possession of child pornography (IC 35‐42‐4‐4c);
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Vicarious sexual gratification (IC 35‐42‐4‐5);
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Child solicitation (IC 35‐42‐4‐6);
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Child seduction (IC 35‐42‐4‐7);
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Sexual misconduct with a minor as a felony (IC 35‐42‐4‐9); or
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Incest (IC 35‐46‐1‐3), if the victim is less than 18 years of age
4. An organization making a request under IC 10‐13‐3‐36 must include proof of its not‐for‐profit
status. A copy of the “Certificate of Good Standing,” issued by the Secretary of State’s office,
will suffice. Please check the appropriate line if requesting the report at no charge under the
provisions set forth in IC 10‐13‐3‐36:
Yes______________
No_______________
Please provide all of the information requested by this office and required under state law to expedite
the response and return of information. If the answer to Item #4 was “no,” a cashier’s check or money
order for $7.00 (made payable to the Monroe County Sheriff’s Office) is required for processing. Please
mail this form and payment to:
Monroe County Sheriff’s Office
*Note – When mailing a request
Records Division
your signature must be notarized
301 N. College Ave.
Bloomington, IN 47404
WARNING: PENALTY FOR MISUSE OF INFORMATION
A non‐criminal justice organization or individual receiving a limited criminal history may not utilize it for purposes other than those stated in
the request or which deny the subject any civil right to which the subject is entitled. Under IC 10‐13‐3‐27, any person who uses limited
criminal history for any purpose not specified in the request commits a Class A Misdemeanor offense.
I affirm, under the penalty of perjury, the limited criminal history information requested will be used
as specified:
Printed name of requester:_______________________________________________________
Signature of requester:__________________________________________________________
Date:__________________________________
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
OFFICE USE ONLY
No record on file
Record inspected
Record released
Information provided not verified by fingerprints
Fee:_______________ Employee:_______________________ Date:________________
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