Form Dci-77 - Criminal History Record Check Request
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1
2STATE OF IOWA
Criminal History Record Check
Request Form
DCI Account Number: _________________
(if applicable)
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:
I am requesting an Iowa Criminal History Record Check on:
Last Name
First Name
Middle Name
(mandatory)
(mandatory)
(recommended)
Date of Birth
Gender
Social Security Number
(
)
(
)
(mandatory)
mandatory
recommended
Male
Female
Waiver Information:
Without a signed waiver from the subject of the request, a complete criminal history record may not
be releasable, per Code of Iowa, Chapter 692.2. For complete criminal history record information, as allowed by law, always
obtain a waiver signature from the subject of the request.
Waiver Release
: I hereby give permission for the above requesting official to conduct an Iowa criminal history record check with the Division of Criminal
Investigation (DCI). Any criminal history data concerning me that is maintained by the DCI may be released as allowed by law.
Waiver Signature
: ___________________________________________________________________________
Iowa Criminal History Record Check Results
(DCI use only)
As of ___________________, a search of the provided name and date of birth revealed:
No Iowa Criminal History Record found with DCI
Iowa Criminal History Record attached, DCI #______________
DCI initials
______________
DCI-77 (08/25/10)
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