SP 4-164 (7-2009)	PENNSYLVANIA STATE POLICE

REQUEST FOR CRIMINAL RECORD CHECK

This form is to be completed in ink by the requester – (information will be mailed to the requester only). If this form is not legible or not properly completed, it will be returned unprocessed to the requester. A response may take four weeks or longer. Warning: A person commits a misdemeanor of the third degree if he/she makes a written false statement, which he/she does not believe to be true.

TRY OUR WEBSITE FOR A QUICKER RESPONSE https://epatch.state.pa.us

NAME/ REQUESTER
	
ADDRESS
	
CITY/STATE/ ZIP CODE

CONTACT TELEPHONE NUMBER (INCLUDING AREA CODE)

FOR CENTRAL REPOSITORY USE ONLY CONTROL NUMBER

AFTER COMPLETION MAIL TO:

PENNSYLVANIA STATE POLICE CENTRAL REPOSITORY – 164 1800 ELMERTON AVENUE HARRISBURG, PA 17110-9758

Local Number 717-425-5546

1-888-QUERYPA (1-888-783-7972)

DO NOT SEND CASH OR PERSONAL CHECK
CHECK ONE BLOCK

INDIVIDUAL/NONCRIMINAL JUSTICE AGENCY – ENCLOSE A CERTIFIED CHECK/MONEY ORDER IN THE AMOUNT OF $10.00, PAYABLE TO:
“COMMONWEALTH OF PENNSYLVANIA” THE FEE IS NONREFUNDABLE

FEE EXEMPT-NONCRIMINAL JUSTICE AGENCY – NO FEE

-

NAME/SUBJECT OF RECORD CHECK (FIRST)

-

(MIDDLE)	(LAST)

MAIDEN NAME AND/OR ALIASES	SOCIAL SECURITY NUMBER	DATE OF BIRTH	SEX	RACE (MM/DD/YYYY)

The Pennsylvania State Police response will be based on the comparison of the data provided by the requester against the information contained in the files of the Pennsylvania State Police Central Repository only

REASON FOR REQUEST: All requests $10.00
***MAKE ALL MONEY ORDERS PAYABLE TO: COMMONWEALTH OF PENNSYLVANIA *** ◄◄◄◄◄◄CHECK BOX THAT MOST APPLIES TO THE PURPOSE OF THIS REQUEST►►►►►►

INTERNATIONAL ADOPTION - INTERNATIONAL ADOPTION MUST BE NOTARIZED.

ADOPTION (DOMESTIC)

ATTORNEY

BANKING

BAR ASSOCIATION

CHURCH

CHILD CARE

EDUCATION

ELDER CARE

EMERGENCY MANAGEMENT

EMPLOYMENT/SCREENING

FOSTER CARE

HEALTHCARE

HOUSING

INSURANCE LICENSE

MENTAL HEALTH

NURSE AID TRAINING

OTHER 	_________________     

PASSPORT

PRIVATE INVESTIGATIONS

SOCIAL SERVICES

TENANT CHECK

VISA

VOLUNTEER AMBULANCE/FIREFIGHTER

VOLUNTEER

ACCESS & REVIEW - (NOT FOR EMPLOYMENT PURPOSES. MUST BE MAILED INTO THE CENTRAL REPOSITORY.)

AVAILABLE ONLY TO SUBJECT OF RECORD OR LEGAL REPRESENTATIVE WITH LEGAL AFFIDAVIT ATTACHED FOR THE PURPOSE OF REVIEWING YOUR CRIMINAL HISTORY.

Homeland Security is Everyone’s Responsibility - Pennsylvania Terrorism Tip Line 1-888-292-1919