Form DSSP256 "Criminal History Record Information Release Authorization Form" - New Hampshire

What Is Form DSSP256?

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 July 15, 2016;
  • 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 DSSP256 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 DSSP256 "Criminal History Record Information Release 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
CRIMINAL HISTORY RECORD INFORMATION RELEASE AUTHORIZATION FORM
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
SECTION II
(
)
PLEASE PRINT CLEARLY
NAME___________________________________________
I hereby authorize the release of my criminal record
conviction(s), if any, to the following individual:
LAST
(MAIDEN/ALIAS)
FIRST
MI
________________________________________________
ADDRESS_______________________________________
NAME OF PERSON/ENTITY TO RECEIVE RECORD
STREET
CITY
STATE
ZIP CODE
_______________________________________
ADDRESS
DATE OF BIRTH___________HAIR COLOR______EYE COLOR________
STREET
CITY
STATE
ZIP CODE
_______________________________________________
SEX
_____ DRIVER LICENSE NUMBER________________________STATE______
YOUR SIGNATURE
DATE
PURPOSE OF RECORD: Housing
Employment
Annulment/Expungement
Other _______________________________________________________________
___________________________________________________________________
NOTARY’S SIGNATURE
DATE
My signature below certifies I am the individual listed above and the information provided is true
(AFFIX Seal)
(comm.. Exp.)
YOUR SIGNATURE: _______________________________ DATE_______
Signed under penalty of unsworn falsification pursuant to RSA 641:3
_________________________________________________________
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.
Prepaid Acc’t Number______________
To prevent a delay in processing, I have enclosed a self-addressed envelope.
A $25.00 fee is required for each request. Make checks payable to: State of NH – Criminal Records.
DSSP256
(Effective 7/15/16)
State of New Hampshire
Criminal Records Unit
Department of Safety
33 Hazen Drive, Concord, NH 03305
DIVISION OF STATE POLICE
CRIMINAL HISTORY RECORD INFORMATION RELEASE AUTHORIZATION FORM
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
SECTION II
(
)
PLEASE PRINT CLEARLY
NAME___________________________________________
I hereby authorize the release of my criminal record
conviction(s), if any, to the following individual:
LAST
(MAIDEN/ALIAS)
FIRST
MI
________________________________________________
ADDRESS_______________________________________
NAME OF PERSON/ENTITY TO RECEIVE RECORD
STREET
CITY
STATE
ZIP CODE
_______________________________________
ADDRESS
DATE OF BIRTH___________HAIR COLOR______EYE COLOR________
STREET
CITY
STATE
ZIP CODE
_______________________________________________
SEX
_____ DRIVER LICENSE NUMBER________________________STATE______
YOUR SIGNATURE
DATE
PURPOSE OF RECORD: Housing
Employment
Annulment/Expungement
Other _______________________________________________________________
___________________________________________________________________
NOTARY’S SIGNATURE
DATE
My signature below certifies I am the individual listed above and the information provided is true
(AFFIX Seal)
(comm.. Exp.)
YOUR SIGNATURE: _______________________________ DATE_______
Signed under penalty of unsworn falsification pursuant to RSA 641:3
_________________________________________________________
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.
Prepaid Acc’t Number______________
To prevent a delay in processing, I have enclosed a self-addressed envelope.
A $25.00 fee is required for each request. Make checks payable to: State of NH – Criminal Records.
DSSP256
(Effective 7/15/16)
State of New Hampshire
Criminal Records Unit
Department of Safety
33 Hazen Drive, Concord, NH 03305
DIVISION OF STATE POLICE
CRIMINAL HISTORY RECORD INFORMATION RELEASE AUTHORIZATION FORM
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
SECTION II
(
)
PLEASE PRINT CLEARLY
NAME___________________________________________
I hereby authorize the release of my criminal record
conviction(s), if any, to the following individual:
LAST
(MAIDEN/ALIAS)
FIRST
MI
1
________________________________________________
ADDRESS_______________________________________
NAME OF PERSON/ENTITY TO RECEIVE RECORD
STREET
CITY
STATE
ZIP CODE
3
_______________________________________
ADDRESS
DATE OF BIRTH___________HAIR COLOR______EYE COLOR________
STREET
CITY
STATE
ZIP CODE
_______________________________________________
SEX
_____ DRIVER LICENSE NUMBER________________________STATE______
YOUR SIGNATURE
DATE
PURPOSE OF RECORD: Housing
Employment
Annulment/Expungement
4
2
Other _______________________________________________________________
___________________________________________________________________
NOTARY’S SIGNATURE
DATE
My signature below certifies I am the individual listed above and the information provided is true
(AFFIX Seal)
(comm.. Exp.)
YOUR SIGNATURE: _______________________________ DATE_______
5
Signed under penalty of unsworn falsification pursuant to RSA 641:3
___________________________________________________________
SIGNATURE OF PERSON/ENTITY TO RECEIVE RECORD
DATE
RECORD CHALLENGE
6
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.
7
To prevent a delay in processing, I have enclosed a self-addressed envelope
A $25.00 fee is required for each request. Make checks payable to: State of NH – Criminal Records.
New Hampshire Department of Safety
DIVISION OF STATE POLICE
Central Repository for Criminal Records
CRIMINAL HISTORY RECORD INFORMATION RELEASE AUTHORIZATION FORM
INSTRUCTION SHEET
The state police Criminal Records Unit has revamped the authorization form to
obtain Criminal History Record Information (CHRI) record checks. The revamped
request form will replace all previous forms currently being used. Please
substitute the attached revised form for what you have been using. An updated
electronic version is also on the Criminal Records Unit website.
The below step by step instructions will assist you in completing the form:
1. This section requires the name and Personal Identifying Information (PII) of the
individual of whom you are requesting a criminal history record. Please print the last
name, maiden (if applicable), first and middle initial; the physical address, date of
birth, hair and eye color, sex, and state and number of the driver’s license.
2. This section identifies the reason why a CHRI is being requested. The majority of
CHRI requests are for housing, employment, or annulment purposes; all other
reasons should be noted on the “other” line. The individual must sign and date on
this line. This acknowledges to the Criminal Records Unit that the individual gives
his or her consent to a CHRI check and that the results will be released to the
individual identified in step 3.
3. The individual must sign and date on this line. This acknowledges to the Criminal
Records Unit that the individual gives his or her consent to a CHRI check and that
the results will be released to the individual identified in step 1.
4. The individual must sign and date on this line. This acknowledges to the Criminal
Records Unit that the individual gives his or her consent to a CHRI check and that
the results will be released to the school individual identified in step 1.
5. The Notary’s signature and seal signifies that the Releasee’s identity has been
validated.
6. In New Hampshire, under the authority of Administrative Rule Saf-C 5703.12,
anyone with a criminal history record has the right to challenge that record if he or
she believes it may contain inaccurate information.
7. Enclosing a self-addressed envelope will enable a more timely return.
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