Form DSSP380 "New Hampshire Criminal History Record Information Authorization Form" - New Hampshire

What Is Form DSSP380?

This is a legal form that was released by the New Hampshire Department of Safety - a government authority operating within New Hampshire. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 24, 2017;
  • The latest edition provided by the New Hampshire Department of Safety;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DSSP380 by clicking the link below or browse more documents and templates provided by the New Hampshire Department of Safety.

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Download Form DSSP380 "New Hampshire Criminal History Record Information Authorization Form" - New Hampshire

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State of New Hampshire
Criminal Records Unit
Department of Safety
33 Hazen Drive, Concord, NH 03305
DIVISION OF STATE POLICE
NEW HAMPSHIRE CRIMINAL HISTORY RECORD INFORMATION AUTHORIZATION FORM
DRIVER EDUCATION INSTRUCTORS NH RSA 263:44-b II
INSTRUCTIONS
NH RSA 106-B:14 and Administrative Rule Saf-C 5700 authorizes the dissemination of NH Criminal History Record Information (CHRI) for non-
criminal justice purposes. In NH, all CHRI is confidential and released only upon the knowledge and permission of the individual of whom the
request is made. Individuals requesting their own record in person need only to complete Section I. If the CHRI is to be released to a third
party, both Section I and Section II must be completed. All requests by mail must have both sections completed and Section II notarized.
SECTION I
(
)
PLEASE PRINT CLEARLY
Last Name___________________________ First Name _____________________Maiden __________________ MI____
Address________________________________ City_____________________________ State_______ Zip____________
Date of Birth _________________________ Hair Color____________ Eye Color__________
Male
Female
Driver’s License Number___________________________________ State______________
My signature below signifies I am the individual listed above and the information provided is true.
Signature ___________________________________________________ Date ___________________________
Signed under penalty of unsworn falsification pursuant to RSA 641:13
SECTION II
I hereby authorize the release of my criminal record conviction(s), if any, to the following:
Department of Motor Vehicles- Driver Education Section
Address
23 Hazen Dr.
City Concord
State NH Zip
03305
Your Signature_____________________________________________________________ Date___________________
Notary’s Signature __________________________________________________________
(Affix Seal)
Signature of person/entity to receive record _____________________________________
Date _________________
RECORD CHALLENGE
Saf-C 5703.12 Procedure for Correcting a CHRI (a) Persons or their attorneys desiring access to their CHRI for the purpose of challenge or correction shall appear at the
central repository. (b) A copy shall be provided to a person if after review he/she indicates he/she needs the copy to pursue the challenge. (c) Any person making a challenge
shall identify that portion of his/her CHRI which he/she believes to be inaccurate or incorrect, and shall also give a correct version of his/her record with an explanation of the
reason that he/she believes his/her version to be correct. (d) The director shall take the following actions within 30 days of receipt of challenge: (1) Review the records and
contact the law enforcement agency or court which submitted the record to compare the information to determine whether the challenge is valid; (2) If the challenge is valid,
which means there is a discrepancy between the information submitted and the information maintained by the law enforcement agency or court, the record shall be corrected and
the person and appropriate CJAs shall be notified; and (3) If the challenge is invalid, the person shall be informed and advised of the right to appeal pursuant to RSA 541. (e)
When a record has been corrected, the division shall notify all non-criminal justice agencies, to whom the data has been disseminated in the last year, of the correction.(f) The
person shall be entitled to review the information that records the facts, dates, and results of each formal stage of the criminal justice process through which he passes, to ensure
that all such steps are completely and accurately recorded.
WARNING: The Division of State Police is the Criminal Record Repository for the State of New Hampshire. The record you
have received is based only on what has been reported to the Repository and may not be a complete Criminal
History Record of the named individual.
FEES
LIVESCAN - $47.00
INKED - $47.00
NOTE: Make checks payable to: State of NH – Criminal Records
Fingerprint card or completed livescan form must be submitted at the same time as payment and this form.
(Effective 4/24/17)
1
DSSP380
State of New Hampshire
Criminal Records Unit
Department of Safety
33 Hazen Drive, Concord, NH 03305
DIVISION OF STATE POLICE
NEW HAMPSHIRE CRIMINAL HISTORY RECORD INFORMATION AUTHORIZATION FORM
DRIVER EDUCATION INSTRUCTORS NH RSA 263:44-b II
INSTRUCTIONS
NH RSA 106-B:14 and Administrative Rule Saf-C 5700 authorizes the dissemination of NH Criminal History Record Information (CHRI) for non-
criminal justice purposes. In NH, all CHRI is confidential and released only upon the knowledge and permission of the individual of whom the
request is made. Individuals requesting their own record in person need only to complete Section I. If the CHRI is to be released to a third
party, both Section I and Section II must be completed. All requests by mail must have both sections completed and Section II notarized.
SECTION I
(
)
PLEASE PRINT CLEARLY
Last Name___________________________ First Name _____________________Maiden __________________ MI____
Address________________________________ City_____________________________ State_______ Zip____________
Date of Birth _________________________ Hair Color____________ Eye Color__________
Male
Female
Driver’s License Number___________________________________ State______________
My signature below signifies I am the individual listed above and the information provided is true.
Signature ___________________________________________________ Date ___________________________
Signed under penalty of unsworn falsification pursuant to RSA 641:13
SECTION II
I hereby authorize the release of my criminal record conviction(s), if any, to the following:
Department of Motor Vehicles- Driver Education Section
Address
23 Hazen Dr.
City Concord
State NH Zip
03305
Your Signature_____________________________________________________________ Date___________________
Notary’s Signature __________________________________________________________
(Affix Seal)
Signature of person/entity to receive record _____________________________________
Date _________________
RECORD CHALLENGE
Saf-C 5703.12 Procedure for Correcting a CHRI (a) Persons or their attorneys desiring access to their CHRI for the purpose of challenge or correction shall appear at the
central repository. (b) A copy shall be provided to a person if after review he/she indicates he/she needs the copy to pursue the challenge. (c) Any person making a challenge
shall identify that portion of his/her CHRI which he/she believes to be inaccurate or incorrect, and shall also give a correct version of his/her record with an explanation of the
reason that he/she believes his/her version to be correct. (d) The director shall take the following actions within 30 days of receipt of challenge: (1) Review the records and
contact the law enforcement agency or court which submitted the record to compare the information to determine whether the challenge is valid; (2) If the challenge is valid,
which means there is a discrepancy between the information submitted and the information maintained by the law enforcement agency or court, the record shall be corrected and
the person and appropriate CJAs shall be notified; and (3) If the challenge is invalid, the person shall be informed and advised of the right to appeal pursuant to RSA 541. (e)
When a record has been corrected, the division shall notify all non-criminal justice agencies, to whom the data has been disseminated in the last year, of the correction.(f) The
person shall be entitled to review the information that records the facts, dates, and results of each formal stage of the criminal justice process through which he passes, to ensure
that all such steps are completely and accurately recorded.
WARNING: The Division of State Police is the Criminal Record Repository for the State of New Hampshire. The record you
have received is based only on what has been reported to the Repository and may not be a complete Criminal
History Record of the named individual.
FEES
LIVESCAN - $47.00
INKED - $47.00
NOTE: Make checks payable to: State of NH – Criminal Records
Fingerprint card or completed livescan form must be submitted at the same time as payment and this form.
(Effective 4/24/17)
1
DSSP380