Free Division of State Police - New Hampshire


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Date: July 11, 2005
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State: New Hampshire
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http://www.courts.state.nh.us/forms/dssp256.pdf

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Preview Division of State Police
State of New Hampshire
DEPARTMENT OF SAFETY
Richard M. Flynn, Commissioner of Safety
271-2575 Speech/Hearing Impaired TDD Access: Relay NH 1-800-735-2964

Division of State Police
James H. Hayes Safety Building, 33 Hazen Drive, Concord, NH 03305

Colonel Frederick H. Booth

Dear Sir/Madam: The Criminal Records Central Repository collects and distributes criminal history record information (CHRI). CHRI consists of descriptions and notations of arrests, detentions, indictments, information's, formal criminal charges and subsequent dispositions. CHRI is forwarded to the repository from criminal justice agencies throughout the state. In addition, the repository tracks information pertaining to sentencing, correctional supervision and release. Several tiers of rules govern the collection and dissemination of CHRI including the Code of Federal Regulations, the New Hampshire Code of Administrative Rules and state statutes to include RSA 106-B:14 and RSA 106-B:7,1(b). Based upon these rules, law enforcement personnel, or an individual requesting his or her own CHRI, will receive both non-conviction and conviction data. Additionally, any individual or agency may receive the CONVICTION INFORMATION of another, provided they produce a notarized CRIMINAL RECORD RELEASE AUTHORIZATION FORM signed by the individual whose record is sought. To assist you with this transaction, I have enclosed a copy of the required CRIMINAL RECORD RELEASE AUTHORIZATION FORM. FAX OR TELEPHONE REQUESTS WILL NOT BE ACCEPTED. Requests by mail MUST HAVE SECTION II COMPLETED. You may copy the Criminal Record Release Authorization Form as your needs dictate. A fifteen dollar ($15.00) fee is charged for EACH record request. Please make checks payable to NHSP-CRIMINAL RECORDS. To expedite the return of your request, please include a typed self-addressed envelope. Please feel free to visit our website at www.state.nh.us/safety/nhsp/, or if you have any questions, please call (603) 271-2538. Thank you for your anticipated cooperation. Sincerely Jeffrey R. Kellett, Administrator State Police Criminal Records Unit Enclosure

New Hampshire Department of Safety

DIVISION OF STATE POLICE
Central Repository for Criminal Records 33 Hazen Drive, Concord, NH 03305

CRIMINAL RECORD RELEASE AUTHORIZATION FORM
SECTION I
PLEASE TYPE OR PRINT CLEARLY, ALL INFORMATION IN THIS SECTION MUST BE COMPLETED

NAME_______________________________________________________________________
LAST (MAIDEN / ALIAS) FIRST MI

ADDRESS_____________________________________________________________________
STREET CITY STATE ZIP CODE

DATE OF BIRTH_______________ HAIR COLOR_______ EYE COLOR_______ SEX________ DRIVER LICENSE NUMBER________________________________STATE_________________
PURPOSE FOR RECORD: Other______________ Specify My below signature certifies that I am the individual listed above and that the information provided is true. Housing Employment Annulment/Expungement

YOUR SIGNATURE:___________________________________________ DATE_____________
Signed under penalty of unsworn falsification pursuant to RSA 641:3.

SECTION II
IF RECORD IS TO BE MAILED TO YOU, OR RECEIVED BY SOMEONE OTHER THAN YOURSELF,

ALL OF SECTION II MUST BE COMPLETED
I hereby authorize the release of my criminal record conviction(s), if any, to the following individual:

NAME OF PERSON / FIRM TO RECEIVE RECORD

ADDRESS______________________________________________________________________
STREET CITY STATE ZIP CODE

YOUR SIGNATURE______________________________________________DATE___________ NOTARY'S SIGNATURE_______________________________________ DATE______________
(AffixSeal) (Comm Exp.)

________________________________________________________DATE_________________
SIGNATURE OF PERSON / FIRM TO RECEIVE RECORD

NOTE: A $15.00 fee is required for each request - make checks payable to: State of NH Criminal
Records