State Of Iowa Dhs Criminal History Record Check Form B Page 2
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1
2STATE OF IOWA
DHS CRIMINAL HISTORY RECORD CHECK
FORM B
MARSHA MCBEE
IF SING results show further research
TH
5
FLOOR HOOVER BLDG
required of Child Abuse Registry, or if DCI
1305 E WALNUT ST, DES MOINES IA 50319
results show criminal history, send Form B
PHONE 515-281-6832, FAX 515-281-4597
with SING sheet and DCI results to:
PURPOSE:
X Child Day Care 237A.5, 237A.20
Adoption 600.8(1)(2)
Child Abuse 232.71
Foster Care/Group Foster Care 237.8
Institutions/Facility 218.13
Juvenile Homes 232.142
Center Name and Mailing Address
REQUEST
Ankeny Christian Academy
1604 W 1 Street
Ankeny IA 50023
I am requesting an Iowa Criminal History (CCH) check on:
Last Name
First Name
Middle Name
Maiden/Former Name, any Alias (List All)
Sex
Social Security Number
Female
Male
Signature of Requester
Date of Birth
DO NOT WRITE IN THIS AREA – FOR DCI USE ONLY
-------------------------------
RESULTS
As of _____________________________________(date) a name and date of birth check revealed:
____ CCH record attached
____ No CCH record found
DCI Initials __________________
WAIVER
(see reverse side)
I hereby give permission for the above requesting official to conduct an Iowa criminal history check with the
Division of Criminal Investigation. Any information maintained by the DCI may be released as allowed by law.
Signature
Date
Address
City, State, ZIP
595-1396 (8/07)
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