Form #sp 167 - Criminal History Record Name Search Request

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S.P. 167 (Rev. 11-01-05)
CRIMINAL HISTORY RECORD NAME SEARCH REQUEST
PURPOSE OF THIS REQUEST (Check only one):
ADOPTION-DOMESTIC
ADOPTION-INTERNATIONAL
OTHER (please specify): _______________________________
VISA (INTERNATIONAL TRAVEL)
NAME INFORMATION TO BE SEARCHED:
LAST NAME
FIRST NAME
MIDDLE NAME
MAIDEN NAME
RACE
SEX
DATE OF BIRTH
SOCIAL SECURITY NUMBER
/
/
(MM/DD/YYYY)
AFFIDAVIT FOR RELEASE OF INFORMATION:
I hereby give consent and authorize the Virginia State Police to search the files of the Central Criminal Records Exchange for a criminal history record and report the results
of such search to the agent or individual authorized in this document to receive same.
__________________________________________________________________
Signature of Person
State of _______________; County/City of _______________________, to wit: Subscribed and sworn to before me this __________ day of _______________ , 20 ____.
My Commission expires ________________________, 20 ____.
__________________________________________________________________
Signature of Notary Public
-
-
SIGNATURE OF PERSON MAKING REQUEST:
As provided in Section 19.2-389, Code of Virginia, I hereby request the criminal history record of the individual named in Section 1 and swear or affirm I have the consent
of the individual to obtain their record and will not further disseminate the information received, except as provided by law.
__________________________________________________________________
Signature of Person Making Request
State of _______________; County/City of _______________________, to wit: Subscribed and sworn to before me this ___________ day of ______________ , 20 ____.
My Commission expires ________________________, 20 ____.
__________________________________________________________________
Signature of Notary Public
NAME AND MAILING ADDRESS OF AGENCY, INDIVIDUAL OR AUTHORIZED AGENT MAKING REQUEST:
Mail Reply To
:
NAME
ATTENTION
ADDRESS
CITY
STATE
ZIP CODE
FEES FOR SERVICE:
FEES:
* FEES For Volunteers with Non-Profit Organizations:
$15.00
$8.00
CRIMINAL HISTORY SEARCH
CRIMINAL HISTORY SEARCH
-
-
$20.00
$16.00
COMBINATION CRIMINAL HISTORY & SEX OFFENDER SEARCH
COMBINATION CRIMINAL HISTORY & SEX OFFENDER SEARCH
* To be entitled to reduced price, services must be on volunteer basis for a non-profit organization with a tax exempt number. Attach documentation to form which supports volunteering status and
include organization’s name, address, and your tax exempt identification number.
METHOD OF PAYMENT: (Note: Personal Checks Not Accepted)
Mail Request To:
Business or Certified Check or Money Order (payable to Virginia State Police)
OR
Charge Card
MasterCard
Visa
Virginia State Police
-
-
-
Central Criminal Records Exchange
:
Account Number
P.O. Box 85076
/
:
Expiration Date
Richmond, Virginia 23261-5076
:
Signature of Cardholder
_________________________________
Virginia State Police Charge Account Number:
FOR STATE POLICE USE ONLY – DO NOT WRITE BELOW THIS LINE
Response based on comparison of name information submitted in request against a master name index maintained in the Central Criminal Records Exchange only.
C
Purpose code:
No Conviction Data – Does Not Preclude the Existence of an Arrest Record
N
No Criminal Record – Name Search Only
No Criminal Record – Fingerprint Search
O
No Sex Offender Registration Record
Criminal Record Attached
Date ___________________________ By CCRE/ ______________________________________________________________

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