Criminal Offender Record Information (Cori) Fee Waiver Request Form
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1THE COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY
Department of Criminal Justice Information Services
200 Arlington Street, Suite 2200, Chelsea, MA 02150
TEL: 617-660-4600 | TTY: 617-660-4606 | FAX: 617-660-4613
mass.gov/cjis
CRIMINAL OFFENDER RECORD INFORMATION (CORI)
FEE WAIVER REQUEST FORM
An organization may request a waiver of the CORI request fee. To qualify for a fee waiver, the organization
must meet the criteria developed by the DCJIS and posted on our web site at Please
note: Government agencies are fee waived; only non-government organizations should use this form.
To request a waiver of the CORI request fee, please complete all of the fields on this form. The answers you
provide to the four qualifying questions will determine whether a fee waiver will be allowed. The completed
form must be returned to the DCJIS at the address above, ATTN: Legal Department.
Organization Name: __________________________________________________________________
Mailing Address:
__________________________________________________________________
Street Number & Name/P.O. Box Number
Apt./Bldg/Unit
__________________________________________________________________
City
State
Zip
__________________________________________________________________
Contact Name:
Contact Phone:
___________________________________
Contact E-Mail:
__________________________________________________________________
Fee Waiver Qualification Questions:
Yes
No
1. Is your organization certified as a 501C(3) entity?
2. Does your organization provide one or more programs or
activities for children, for the elderly, and/or for the
Yes
No
disabled?
3. What is the average annual percentage of volunteers in your organization?
%
_____
4. What is the average program fee charged by your organization?
______
I swear, under the pains and penalties of perjury, that the information provided in this application is true and
accurate to the best of my knowledge and understanding.
______________________________________________________ ________________________________
Signature
Date
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