Multiple Name Record Request
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2DJ-LE-250A (Rev. 7/11)
STATE OF WISCONSIN
DEPARTMENT OF JUSTICE
DIVISION OF LAW ENFORCEMENT SERVICES
PO Box 2688
WISCONSIN CRIMINAL HISTORY
Crime Information Bureau
Madison, WI 53701-2688
MULTIPLE NAME RECORD REQUEST
Record Check Unit
608/266-5764
A self-addressed, postage-paid envelope must accompany every inquiry. Ensure sufficient postage is included.
See reverse side for more information/instructions.
Return request
To :
__________________________________________
Attn: ____________________________
Phone: _____________________________
Street:
______________________________________________________________________________
FAX: _____________________________
City, State,
Zip:
____________________________________________________________________
E-mail: _______________________________________
Requestor Type –
Request Purpose -
Total Number of
Payment Type –
Check One
Check One
Check One
Requests Submitted
Government Agency $12.00*
General Information
Bill Account
General Public
$12.00*
Public Housing
Number #____________
Nonprofit Org.
$12.00*
Caregiver – General
Amount
(*Add $3 DHS fee)
Public Defender (Fee Exempt)
Child Day Care - Caregiver
Enclosed $____________
(*Add $3 DHS fee)
SPD # _______________________
Provide either Facility # _____________
Multiply the Search Fee (including DHS fee) times
or Certifying Agency # ______________
the Number of Requests to determine the amount to enclose
* Date of Birth
Other Identifying Data
** CIB Use Only
* Last Name
* First Name
Middle
* Sex * Race
(MM/DD/YYYY)
(Soc Sec Num, Maiden name)
(Leave Blank)
*
Required Data – Please type or print legibly
**
CIB will indicate “No Record” or will record the State Identification Number of the corresponding record in this column. The record(s) will be attached to this form and returned.
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