Form Sp 4-164 - Request For Criminal Record Check - Pennsylvania State Police
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1SP 4-164 (12-99)
FOR CENTRAL REPOSITORY USE ONLY
(LEAVE BLANK)
PENNSYLVANIA STATE POLICE
REQUEST FOR CRIMINAL RECORD CHECK
DATE OF REQUEST
PART I: TO BE COMPLETED BY REQUESTER
(INFORMATION WILL BE MAILED TO REQUESTER ONLY)
*** TYPE OR PRINT LEGIBLY WITH INK ***
NOTE:
IF THIS FORM IS NOT LEGIBLE OR NOT PROPERLY COMPLETED, IT WILL BE RETURNED UNPROCESSED TO THE
REQUESTER. A RESPONSE MAY TAKE THREE WEEKS OR LONGER TO PROCESS.
WARNING: A PERSON COMMITS A MISDEMEANOR OF THE THIRD DEGREE IF HE/SHE MAKES A WRITTEN FALSE
STATEMENT, WHICH HE/SHE DOES NOT BELIEVE TO BE TRUE.
REQUESTER
NAME
ADDRESS
CITY
STATE
ZIP
CONTACT TELEPHONE NUMBER (INCLUDING AREA CODE)
REQUESTER IDENTIFICATION (ONLY CHECK ONE BLOCK)
INDIVIDUAL/NONCRIMINAL JUSTICE AGENCY – ENCLOSE A CERTIFIED CHECK/MONEY ORDER IN THE AMOUNT OF $10.00 PAYABLE TO: “COMMONWEALTH OF PENNSYLVANIA.”
THE FEE IS NONREFUNDABLE.
*** DO NOT SEND CASH OR PERSONAL CHECK ***
FEE EXEMPT NONCRIMINAL JUSTICE AGENCY
NAME/SUBJECT OF RECORD CHECK
(LAST)
(FIRST)
(MIDDLE)
MAIDEN NAME AND/OR ALIASES
SOCIAL SECURITY NUMBER (SOC)
DATE OF BIRTH (DOB)
SEX
RACE
REASON FOR REQUEST (CHECK ONE BLOCK)
EMPLOYMENT (IF APPLICABLE, CHECK ONE OF THE FOLLOWING)
ELDER CARE
CHILD CARE
SCHOOL DISTRICT
ADOPTION/FOSTER CARE
Volunteer
OTHER (SPECIFY)
ONLY CHECK THIS BLOCK IF YOU WANT TO REVIEW YOUR ENTIRE CRIMINAL HISTORY
INDIVIDUAL ACCESS AND REVIEW OR FIREARMS CHALLENGE–ENTIRE CRIMINAL HISTORY
(AVAILABLE ONLY TO SUBJECT OF RECORD CHECK OR LEGAL REPRESENTATIVE WITH LEGAL AFFIDAVIT OF LEGAL REPRESENTATIVE ATTACHED)
REQUESTER CHECKLIST
AFTER COMPLETION MAIL TO
PENNSYLVANIA STATE POLICE
DID YOU ENTER THE FULL NAME, DOB, AND SOC?
CENTRAL REPOSITORY – 164
DID YOU ENCLOSE THE $10.00 FEE (CERTIFIED CHECK/MONEY ORDER)?
1800 ELMERTON AVENUE
*** DO NOT SEND CASH OR PERSONAL CHECK ***
HARRISBURG, PA 17110-9758
717-783-9973
DID YOU ENTER YOUR COMPLETE ADDRESS INCLUDING ZIP CODE AND
BUSINESS HOURS 8:15 am - 4:15 pm (Monday – Friday)
TELEPHONE NUMBER IN THE BLOCKS PROVIDED?
PART II: CENTRAL REPOSITORY RESPONSE ONLY
***DO NOT WRITE BELOW THIS LINE***
INQUIRY DISSEMINATED BY
SID NUMBER
INFORMATION DISSEMINATED
NO RECORD
CRIMINAL RECORD ATTACHED
THE INFORMATION DISSEMINATED BY THE CENTRAL REPOSITORY IS BASED ON THE
CERTIFIED BY
FOLLOWING IDENTIFIERS THAT MATCH THOSE FURNISHED BY THE REQUESTER.
NAME
SOCIAL SECURITY NUMBER
DATE OF BIRTH
RACE
SEX
MAIDEN/ALIAS NAME
(DIRECTOR, CENTRAL REPOSITORY)
This response is based on a comparison of data provided by the requester in Part I against the information contained in the files
of the Pennsylvania State Police Central Repository only, and does not preclude the existence of criminal records which might be
contained in the repositories of other local, state, or federal criminal justice agencies.
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