Personal Massachusetts Criminal Record Request

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:
    ______________________________________________
     
    ______________________________________________