Haverhill, MA - Criminal Record Request

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POLICE> OFFICE OF THE POLICE CHIEF

Personal Massachusetts Criminal Record Request (printable version)

If you would like a copy of your own Massachusetts criminal record, complete this form, sign it in front of a notary public, and mail it, along with a self-addressed stamped envelope to this agency. Walk-in service is not available. If you are incarcerated and a notary public is not available, have an official of the correctional facility endorse same. This agency's mailing address is: Criminal History Systems Board, 200 Arlington Street, Suite 2200, Chelsea, MA 02150 ATTN: CORI Unit.

Please be advised that it is unlawful to request or require a person to provide a copy of his criminal offender record information, except as authorized by the Criminal History Systems Board, as per M.G.L.c.6§172.

Please check the appropriate box if this request is for immigration [ ] or adoption [ ] purposes.


Last name	First name	Middle name

Maiden name	Alias

Date of birth (mm/dd/yy)	Social Security number

Street address	Town	State Zipcode

I hereby swear, under the pains and penalties of perjury, that the information I have provided above is true, and to the best of my knowledge and belief.


Signiture of requestor	Date

AUTHENTICATION OF SIGNATURE BY NOTARY PUBLIC OR CORRECTIONAL FACILTIY

, SS.

The above named____________________________, appeared before me, the undersigned authority, this_____________day of

_______________, _____ and acknowledge the foregoing signature to be made of his or her own true free act and deed.


Notary Public		Correctional Facility Official (give rank and title)
My commission expires on:		Correctional Facility Address and Phone: