Criminal Offender Record Information (Cori) Personal Request Form
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4THE COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY
Department of Criminal Justice Information Services
200 Arlington Street, Suite 2200, Chelsea, MA 02150
TEL: 617-660-4640 | TTY: 617-660-4606 | FAX: 617-660-5973
MASS.GOV/CJIS
CRIMINAL OFFENDER RECORD INFORMATION (CORI)
PERSONAL
REQUEST FORM
Use this form only for requesting your own CORI. A bank check or money order for $25.00 must be submitted with
this form. Please note: this is a multi-page request form. Incomplete request forms will not be processed. Requests
must be mailed, along with the accompanying payment or indigency waiver, to the address provided above, ATTN:
CORI Unit.
Request Type Details
*Are you applying for an indigency waiver?
Yes
No
If you are applying for an indigency waiver, please go to
pdf to download the waiver form. You must submit the waiver with the completed application.
If you require a certified copy of your CORI, please check this box.
Requestor Details
Please complete this section using your information. A red asterisk (*) denotes a required field.
*First Name
*Last Name
Suffix
Middle Initial
*Date of Birth
I do not have a Social Security number
*Last 6 digits of Social Security number
*Mailing Address
Street 2
(Apt, Suite,
Street 1
Bldg)
City/Town
State
Zip
Phone
Ext.
Email
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