Form Dssp256 - Criminal History Record Information Release Authorization Form (Page 3 of 3) in pdf

Form Dssp256 - Criminal History Record Information Release Authorization Form Page 3

Central Repository for Criminal Records

CRIMINAL HISTORY RECORD INFORMATION RELEASE AUTHORIZATION FORM

INSTRUCTION SHEET

The state police Criminal Records Unit has revamped the authorization form to

obtain Criminal History Record Information (CHRI) record checks. The revamped

request form will replace all previous forms currently being used. Please

substitute the attached revised form for what you have been using. An updated

electronic version is also on the Criminal Records Unit website.

The below step by step instructions will assist you in completing the form:

1. This section requires the name and Personal Identifying Information (PII) of the

individual of whom you are requesting a criminal history record. Please print the last

name, maiden (if applicable), first and middle initial; the physical address, date of

birth, hair and eye color, sex, and state and number of the driver’s license.

2. This section identifies the reason why a CHRI is being requested. The majority of

CHRI requests are for housing, employment, or annulment purposes; all other

reasons should be noted on the “other” line. The individual must sign and date on

this line. This acknowledges to the Criminal Records Unit that the individual gives

his or her consent to a CHRI check and that the results will be released to the

individual identified in step 3.

3. The individual must sign and date on this line. This acknowledges to the Criminal

Records Unit that the individual gives his or her consent to a CHRI check and that

the results will be released to the individual identified in step 1.

4. The individual must sign and date on this line. This acknowledges to the Criminal

Records Unit that the individual gives his or her consent to a CHRI check and that

the results will be released to the school individual identified in step 1.

5. The Notary’s signature and seal signifies that the Releasee’s identity has been

validated.

6. In New Hampshire, under the authority of Administrative Rule Saf-C 5703.12,

anyone with a criminal history record has the right to challenge that record if he or

she believes it may contain inaccurate information.

7. Enclosing a self-addressed envelope will enable a more timely return.

Form Dssp256 - Criminal History Record Information Release Authorization Form Page 3