Free DSSP256 - New Hampshire

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:

Housing Employment Annulment/Expungement Other __________

My below signature certifies I am the individual listed above and that the information provided is true.

YOUR SIGNATURE:________________________________________ DATE___________
Signed under penalty of unsworn falsification pursuant to NH 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____________
(Affix Seal) (Comm. Exp.)

_________________________________________________________ DATE___________
SIGNATURE OF PERSON / FIRM TO RECEIVE RECORD NOTE: A $25.00 fee is required for each request- make checks payable to: State of NH ­ Criminal Records.