Form Dssp256 - Criminal History Record Information Release Authorization Form printable pdf download

State of New Hampshire

Criminal Records Unit

Department of Safety

33 Hazen Drive, Concord, NH 03305

DIVISION OF STATE POLICE

CRIMINAL HISTORY RECORD INFORMATION RELEASE AUTHORIZATION FORM

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. Individuals requesting their own record in person need only to complete Section I. If the CHRI is to be released to a third

party, 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

(

)

PLEASE PRINT CLEARLY

NAME___________________________________________

I hereby authorize the release of my criminal record

conviction(s), if any, to the following individual:

LAST

(MAIDEN/ALIAS)

FIRST

________________________________________________

ADDRESS_______________________________________

NAME OF PERSON/ENTITY TO RECEIVE RECORD

STREET

CITY

STATE

ZIP CODE

_______________________________________

ADDRESS

DATE OF BIRTH___________HAIR COLOR______EYE COLOR________

STREET

CITY

STATE

ZIP CODE

_______________________________________________

SEX

_____ DRIVER LICENSE NUMBER________________________STATE______

YOUR SIGNATURE

DATE

PURPOSE OF RECORD: Housing

Employment

Annulment/Expungement

Other _______________________________________________________________

___________________________________________________________________

NOTARY’S SIGNATURE

DATE

My signature below certifies I am the individual listed above and the information provided is true

(AFFIX Seal)

(comm.. Exp.)

YOUR SIGNATURE: _______________________________ DATE_______

Signed under penalty of unsworn falsification pursuant to RSA 641:3

_________________________________________________________

SIGNATURE OF PERSON/ENTITY TO RECEIVE RECORD

DATE

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.

Prepaid Acc’t Number______________

To prevent a delay in processing, I have enclosed a self-addressed envelope.

A $25.00 fee is required for each request. Make checks payable to: State of NH – Criminal Records.

DSSP256

(Effective 7/15/16)