Criminal Record Request Form

Criminal Record Request Form

This Criminal Record Request Form is executed on this day: Month Day Year , by and between Requestor Name: of Address: (Requestor), and Custodian of Records / Agency Name: of Address: (Agency).

RECITALS

WHEREAS, Requestor seeks disclosure of criminal history records, arrest reports, and related documents pertaining to the individual identified below for permitted purposes described herein; and

WHEREAS, Agency is the custodian of the requested records and has control over access, release conditions, and any legally authorized redactions or denials; and

WHEREAS, the parties wish to set forth the terms, authorizations, and certifications governing the production, use, and limitation of the requested records.

NOW, THEREFORE, in consideration of the mutual covenants contained herein, the parties agree as follows:

1. DEFINITIONS

For purposes of this Form, "Requested Records" means criminal history records, arrest reports, disposition documents, fingerprint cards, booking photographs, warrant information, and any other official documents in Agency's possession responsive to the request identified in Section 2 below.

2. SCOPE OF REQUEST

Requestor hereby requests production of the Requested Records for the individual whose identifying information is provided below. Requestor limits the request to the following types of records (check all that apply):

Criminal history summary
Arrest reports
Court dispositions and final judgments
Fingerprint cards
Booking photographs
Outstanding warrant information

Date range for records requested: From To .

3. IDENTIFYING INFORMATION

4. AUTHORIZATION, CERTIFICATION AND RELEASE

Requestor certifies under penalty of perjury that the foregoing identifying information is true and correct to the best of Requestor's knowledge, and authorizes Agency to disclose the Requested Records in accordance with this Form. Requestor further authorizes the release of non-confidential portions of the Requested Records to the Requestor or a designated recipient identified below.

Requestor hereby releases Agency and its officials, employees, and agents from any liability arising from the release of records in accordance with this Form, except for willful misconduct or gross negligence. Requestor acknowledges that certain records may be withheld or redacted pursuant to law.

5. USE LIMITATIONS AND CONFIDENTIALITY

Requestor agrees that the Requested Records will be used only for the permitted purpose stated in this Form and will not be disseminated, published, sold, or otherwise redistributed in violation of applicable law. Requestor will secure and protect records from unauthorized access and will promptly notify Agency of any known unauthorized disclosure.

6. FEES AND PAYMENT

Requestor agrees to pay reasonable reproduction and processing fees in accordance with Agency's fee schedule. Payment may be required in advance for estimated costs. If fees exceed the estimated amount, Agency will provide notice and will not proceed without additional written authorization.

7. PROCESSING, DELIVERY, AND RETENTION

Agency will use reasonable efforts to process this request within the Agency's standard processing times but makes no absolute guarantee as to delivery dates. Agency may redact or withhold records to the extent required by law.

8. DENIAL, REDACTION, AND APPEAL

If Agency denies the request or redacts any portion of the Requested Records, Agency will provide a written statement of reasons and identify the legal basis for the denial or redact. Requestor may appeal a denial in accordance with Agency policy by submitting a written request for review to the appeals contact below within the time period specified by applicable law.

9. NOTICES

Formal notices, requests for clarification, or appeals must be delivered to the addresses below by personal service, certified mail, or other verifiable delivery method.

10. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Form shall be governed by and construed in accordance with the laws of the jurisdiction in which Agency maintains the requested records, without regard to principles of conflicts of law. This Form constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior understandings and communications, whether written or oral, concerning the same. If any provision of this Form is determined to be invalid or unenforceable, such provision shall be severed and the remainder of this Form shall remain in full force and effect.

11. AMENDMENTS; WAIVER; COUNTERPARTS

Any amendment to this Form must be in writing signed by both parties. Failure by either party to enforce any provision shall not constitute a waiver of that provision or of the right to enforce it later. This Form may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

12. CERTIFICATION

By signing below, Requestor certifies under penalty of perjury that the information provided in this Form is true and correct, that the records requested are for the Permitted Purpose stated above, and that Requestor understands the limitations and conditions on disclosure contained herein.

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