Fill and Sign the Massachusetts Cori Records Form

REQUEST FOR PUBLICLY ACCESSIBLE MASSACHUSETTS CORI It is lawful to request this agency to provide a copy of another person’s publicly accessible adult conviction record. For the adult conviction record to be “publicly accessible” the person whose record is requested must have been convicted of a crime punishable by a sentence of five years or more, or has been convicted of any crime and sentenced to any term of imprisonment, and at the time of the request: 1. is serving a sentence of probation or incarceration, or is under the custody of the parole board; or 2. having been convicted of a misdemeanor, has been released from all custody or supervision not more than one year; or 3. having been convicted felony, has been released from all custody or supervision for not more than two years; or 4. having been sentenced to the custody of the department of correction, has finally been discharged therefrom, either having been denied release on parole or having been returned to penal custody for violating parole for not more than three years. Directions: Please fill this request form out as completely as possible. The more information you are able to provide, the more easily this agency will be able to process your request. A non-refundable processing fee of $30.00 is charged for each record requested and must be included with your request(s) . There will be no exceptions made to this rule. Only checks or money orders made payable to the Commonwealth of Massachusetts will be accepted. A self-addressed, stamped envelope must also be enclosed with your request(s). Walk in requests or faxed requests will not be accepted. Requests will be processed in the order in which they are received. Mail all requests to: the Criminal History Systems Board, 200 Arlington Street, Suite 2200, Chelsea, MA 02150, ATTN: CORI Unit. All requests must be typed. Requests containing any illegible identifying information will be returned. If you are making more than one request, please copy this form and fill in the requested identifying information accordingly. 1. _______________________________ Last name, First name, Middle initial ________________________ Maiden name ________________________ Alias ________________________ ID Theft Index PIN Number (if applicable, not required) ________________________ Date of Birth (MM/DD/YY) ________________________ Social Security Number (requested but not required) 2. _______________________________ Last name, First name, Middle initial ________________________ Maiden name ________________________ Alias ________________________ ID Theft Index PIN Number (if applicable, not required) ________________________ Date of Birth (MM/DD/YY) ________________________ Social Security Number (requested but not required)