Form S.p. 167 - Criminal History Record Name Search Request - Virginia State Police printable pdf download

S.P. 167 (Rev. 11-01-2010)

CRIMINAL HISTORY RECORD NAME SEARCH REQUEST

PURPOSE OF THIS REQUEST (Check only one):

ADOPTION-DOMESTIC

ADOPTION-INTERNATIONAL COUNTRY:________________

VISA (INTERNATIONAL TRAVEL)

OTHER (please specify):__________________________________

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 ____. My registration # is: ___________________

______________________________________________________________

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 ____. My registration # is: ___________________

______________________________________________________________

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

$20.00

$16.00

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)

Charge Card

MasterCard

Visa

Virginia State Police

Central Criminal Records Exchange - NF

Account Number

P.O. Box 85076

Expiration Date:

Richmond, Virginia 23261-5076

Signature of Cardholder: ______________________________________________

Virginia State Police Charge Account Number: ___________________

ATTN: NEW FORM

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.

□ No Conviction Data – Does Not Preclude the Existence of an Arrest Record

Purpose code:

□ No Criminal Record – Name Search Only

□ No Criminal Record – Fingerprint Search

□ No Sex Offender Registration Record

□ Criminal Record Attached

Date ___________________________ By CCRE/ ______________________________________________________________