Form #sp 167 - Criminal History Record Name Search Request

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S.P. 167 (Rev. 11-01-05)

CRIMINAL HISTORY RECORD NAME SEARCH REQUEST

PURPOSE OF THIS REQUEST (Check only one):

ADOPTION-DOMESTIC

ADOPTION-INTERNATIONAL

OTHER (please specify): _______________________________

VISA (INTERNATIONAL TRAVEL)

NAME INFORMATION TO BE SEARCHED:

LAST NAME

FIRST NAME

MIDDLE NAME

MAIDEN NAME

RACE

SEX

DATE OF BIRTH

SOCIAL SECURITY NUMBER

(MM/DD/YYYY)

AFFIDAVIT FOR RELEASE OF INFORMATION:

I hereby give consent and authorize the Virginia State Police to search the files of the Central Criminal Records Exchange for a criminal history record and report the results

of such search to the agent or individual authorized in this document to receive same.

__________________________________________________________________

Signature of Person

State of _______________; County/City of _______________________, to wit: Subscribed and sworn to before me this __________ day of _______________ , 20 ____.

My Commission expires ________________________, 20 ____.

__________________________________________________________________

Signature of Notary Public

SIGNATURE OF PERSON MAKING REQUEST:

As provided in Section 19.2-389, Code of Virginia, I hereby request the criminal history record of the individual named in Section 1 and swear or affirm I have the consent

of the individual to obtain their record and will not further disseminate the information received, except as provided by law.

__________________________________________________________________

Signature of Person Making Request

State of _______________; County/City of _______________________, to wit: Subscribed and sworn to before me this ___________ day of ______________ , 20 ____.

My Commission expires ________________________, 20 ____.

__________________________________________________________________

Signature of Notary Public

NAME AND MAILING ADDRESS OF AGENCY, INDIVIDUAL OR AUTHORIZED AGENT MAKING REQUEST:

Mail Reply To

NAME

ATTENTION

ADDRESS

CITY

STATE

ZIP CODE

FEES FOR SERVICE:

FEES:

* FEES For Volunteers with Non-Profit Organizations:

$15.00

$8.00

CRIMINAL HISTORY SEARCH

$20.00

$16.00

COMBINATION CRIMINAL HISTORY & SEX OFFENDER SEARCH

* To be entitled to reduced price, services must be on volunteer basis for a non-profit organization with a tax exempt number. Attach documentation to form which supports volunteering status and

include organization’s name, address, and your tax exempt identification number.

METHOD OF PAYMENT: (Note: Personal Checks Not Accepted)

Mail Request To:

Business or Certified Check or Money Order (payable to Virginia State Police)

Charge Card

MasterCard

Visa

Virginia State Police

Central Criminal Records Exchange

Account Number

P.O. Box 85076

Expiration Date

Richmond, Virginia 23261-5076

Signature of Cardholder

_________________________________

Virginia State Police Charge Account Number:

FOR STATE POLICE USE ONLY – DO NOT WRITE BELOW THIS LINE

Response based on comparison of name information submitted in request against a master name index maintained in the Central Criminal Records Exchange only.

□

Purpose code:

No Conviction Data – Does Not Preclude the Existence of an Arrest Record

□

No Criminal Record – Name Search Only

No Criminal Record – Fingerprint Search

□

No Sex Offender Registration Record

Criminal Record Attached

Date ___________________________ By CCRE/ ______________________________________________________________