Form Dci-67 - Criminal History Record Check Billing Form - Iowa Division Of Criminal Investigation
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1State of IOWA and FBI
Criminal History Record Check
Billing Form
Date:
Account Number:
To:
Iowa Division of Criminal Investigation
From:
st
Support Operations Bureau, 1
Floor
th
215 E. 7
Street
Des Moines, Iowa 50319
(515) 725-6066
(515) 725-6080 Fax
Phone:
Fax:
STATE of IOWA Criminal History Record Check Request Form
SING USERS: Do not complete this section; proceed to the National Check section for fingerprints.
Mail Back Results
$15.00
*Each last name requires a Request Form and payment.
Fax Back Results
Number of State checks submitted: x
*If neither box above is checked, results will be
Subtotal: $
mailed back to the address provided.
EMPLOYEE National Criminal History Record Check
$26.00
Number of Employee fingerprint cards submitted:
x
*All National check results will be mailed to the Qualified Entity.
Subtotal: $
VOLUNTEER National Criminal History Record Check
$13.00
Number of Volunteer fingerprint cards submitted: x
*All National check results will be mailed to the Qualified Entity.
Subtotal: $
TOTAL: $
METHOD OF PAYMENT
(Checks should be made payable to the Iowa Division of Criminal Investigation)
Check
Cash
Money Order
Pre-paid Account
Interagency
MasterCard/Visa/Discover:
Expiration Date:
Cardholder’s Name:
CSV Code
(required):
DCI-67 (11/30/15)
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Parent category: Legal