Form 595-1396 - Dhs Criminal History Record Check Form B - State Of Iowa printable pdf download

Form 595-1396 - Dhs Criminal History Record Check Form B - State Of Iowa

STATE OF IOWA

DHS CRIMINAL HISTORY RECORD CHECK

FORM B

FROM

Iowa Division of Criminal Investigations

Bureau of Identification, 1st Floor

215 E 7th Street

Des Moines, Iowa 50319

PURPOSE:

Child Day Care 237A.5, 237A.20

Adoption 600.8(1)(2)

Child Abuse 232.71

Foster Care/Group Foster Care 237.8

Institutions/Facility 218.13

Juvenile Homes 232.142

REQUEST

I am requesting an Iowa criminal history (CCH) check on:

Last Name

First Name

Middle Name

Maiden Name

Sex

Social Security Number

Date of Birth

Signature of Requester

RESULTS

As of ________________________________________ (date) a name and date of birth check

revealed:

CCH record attached

No CCH record found

DCI Initials _______________

WAIVER

(see reverse side)

I hereby give permission for the above requesting official to conduct an Iowa criminal history check

with the Division of Criminal Investigation. Any information maintained by the DCI may be released

as allowed by law.

Signature

Date

White: Submit to DCI or to County/Region Day Care

Yellow: Control Copy

595-1396 (Rev. 8/07)

Form 595-1396 - Dhs Criminal History Record Check Form B - State Of Iowa