Form 595-1396 "DHS Criminal History Record Check - Form B" - Iowa

Form 595-1396 Printable Pdf
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What Is Form 595-1396?

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

Form Details:

  • Released on August 1, 2007;
  • The latest edition provided by the Iowa Department of Public 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 printable version of Form 595-1396 by clicking the link below or browse more documents and templates provided by the Iowa Department of Public Safety.

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Download Form 595-1396 "DHS Criminal History Record Check - Form B" - Iowa

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STATE OF IOWA
DHS CRIMINAL HISTORY RECORD CHECK
FORM B
FROM
:
Iowa Division of Criminal Investigations
:
TO
Bureau of Identification, 1st Floor
215 E 7th Street
Des Moines, Iowa 50319
PURPOSE:
Child Day Care 237A.5, 237A.20
Adoption 600.8(1)(2)
Child Abuse 232.71
Foster Care/Group Foster Care 237.8
Institutions/Facility 218.13
Juvenile Homes 232.142
REQUEST
I am requesting an Iowa criminal history (CCH) check on:
Last Name
First Name
Middle Name
Maiden Name
Sex
Social Security Number
Date of Birth
Signature of Requester
RESULTS
As of ________________________________________ (date) a name and date of birth check
revealed:
CCH record attached
No CCH record found
DCI Initials _______________
WAIVER
(see reverse side)
I hereby give permission for the above requesting official to conduct an Iowa criminal history check
with the Division of Criminal Investigation. Any information maintained by the DCI may be released
as allowed by law.
Signature
Date
White: Submit to DCI or to County/Region Day Care
Yellow: Control Copy
595-1396 (Rev. 8/07)
1
STATE OF IOWA
DHS CRIMINAL HISTORY RECORD CHECK
FORM B
FROM
:
Iowa Division of Criminal Investigations
:
TO
Bureau of Identification, 1st Floor
215 E 7th Street
Des Moines, Iowa 50319
PURPOSE:
Child Day Care 237A.5, 237A.20
Adoption 600.8(1)(2)
Child Abuse 232.71
Foster Care/Group Foster Care 237.8
Institutions/Facility 218.13
Juvenile Homes 232.142
REQUEST
I am requesting an Iowa criminal history (CCH) check on:
Last Name
First Name
Middle Name
Maiden Name
Sex
Social Security Number
Date of Birth
Signature of Requester
RESULTS
As of ________________________________________ (date) a name and date of birth check
revealed:
CCH record attached
No CCH record found
DCI Initials _______________
WAIVER
(see reverse side)
I hereby give permission for the above requesting official to conduct an Iowa criminal history check
with the Division of Criminal Investigation. Any information maintained by the DCI may be released
as allowed by law.
Signature
Date
White: Submit to DCI or to County/Region Day Care
Yellow: Control Copy
595-1396 (Rev. 8/07)
1
WAIVER:
Iowa law does not require waiver. However, without a waiver any arrest over 18 months old without a
disposition, cannot be given to a non-law enforcement agency.
Deferred judgments where DCI has received notice of successful completion of probation also cannot
be given out to non-law enforcement agencies without a signed waiver.
General Information:
The information requested is based on name and exact date of birth only. Without fingerprints a
positive identification cannot be assured. If a person disputes the accuracy of information maintained
by the Department, they may challenge the information by writing to the address on the front of this
form or personally appearing at DCI headquarters during normal working hours.
The records maintained by the Iowa Department of Public Safety are based upon reports from other
criminal justice agencies and therefore, the Department cannot guarantee the completeness of the
information provided.
The criminal history check is of the Iowa Central Repository only. No other state or federal agency
records can be searched under current law.
In Iowa, a deferred judgment is not considered a conviction once the defendant has been discharged
after successfully completing probation. However, it should be noted that a deferred judgment may
still be considered as an offense when considering charges for certain specified multiple offense
crimes, i.e., second offense OWI. If a disposition reflects that a deferred judgment was given, you may
want to inquire of the individual his or her current status.
Any questions in reference to Iowa criminal history records can be answered by writing to the address
on the front of this form or calling (515) 725-6066 between 8:00 a.m. and 4:30 p.m., Monday through
Friday.
If the “No CCH record found” box is checked, it could also mean that information in the file is not
releasable per Iowa law without a waiver.
Reminder:
Each agency, other than day care, should submit a self-addressed envelope with their requests.
This will expedite the process.
FORM B IS FOR THE SPECIFIC PURPOSE SET OUT ON THE FRONT. COURT
ORDERED HOME STUDY MUST SUBMIT FORM A WITH PAYMENT.
595-1396 (Rev. 8/07)
2
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Form 595-1396 Printable Pdf
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