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Indiana State Police
Criminal History Information
Limited Criminal History / Review Challenge (Full) 317-233-5424 www.IN.gov/ISP

ID Billing Number Or Customer ID #

PLEASE TYPE OR PRINT ALL INFORMATION RECORD CHECK ON:

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M = Male F = Female

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First Name .
I = American Indian / Alaskan A= Asian / Pacific Islander W = White B = Black U = Unknown M = Multi Racial

Last Name

M.I

Date of Birth MM / DD / YYYY

Sex

Race

REASON FOR SEARCH
________________________ ________________________
P.I. License, Bar Exams (list state), Adoption, Visa, Employment , Immigration (list Country), Licensing (type), etc.

Name Mailing Address: City, State, Zip Code
ATTENTION:

(where this response will be sent )

( ) Daytime Phone Number

Limited Criminal History Information ­ Reason for Request The cost is $7.00. Mark an "X" in one box below for this request.
Certified check or money order must be enclosed if request is mailed. Cash will be accepted only in person. [Correct Change] Has applied for employment with a non-criminal justice organization or individual; Has applied for a license and has provided criminal history data as required by law to be provided in connection with the license; Teachers (3) Employment with a state or local governmental entity. (4) Is a candidate for public office or a public official; (5) Is in the process of being apprehended by a law enforcement agency; (6) Is placed under arrest for the alleged commission of a crime; (7) Has charged that his rights have been abused repeatedly by criminal justice agencies; (8) Is the subject of judicial decision or determination with respect to the setting of bond, plea bargaining, sentencing, or probation; (9) Has volunteered services that involve contact with, care of, or supervision over a child who is being placed, matched, or monitored by a social services agency, or a nonprofit corporation; (10) Is employed by an entity that seeks to enter into a contract with a public school (as defined in IC 2010.1-1-2) or a non-public school (as defined in IC 20-10.1-1-3), if the subject of the request is expected to have direct, ongoing contact with school children within the scope of the subject's employment; (11) Has volunteered services at a public school (as defined in IC 20-10.1-1-2) or non-public school (as defined in IC 20-10.1-1-3) that involve contact with, care of, or supervision over a student enrolled in the school; Student Teacher IC 5-2-5-5. (12) Is being investigated for welfare fraud by an investigator of the Division of Family and Children or a county office of family and children; (13) Is being sought by the parent locator service of the Child Support Bureau of the Division of Family and Children; (14) Is or was required to register as a sex and violent offender under IC 5-2-12; or (15) Has been convicted of any of the following: (A) Rape (IC 35-42-4-1), if the victim is less than eighteen (18) years of age. (B) Criminal deviate conduct (IC 35-42-4-2), if the victim is less than eighteen (18) years of age. (C) Child molesting (IC 35-42-4-3). (D) Child exploitation (IC 35-42-4-4(b)). (E) Possession of child pornography (IC 35-42-4-4(c). (F) Vicarious sexual gratification (IC 35-42-4-5). (continued on next page) (1) (2)

State Form #8053 (R8 / 3-09) Approved by State Board of Accounts, 2009

Stock #575

(G) (H) (I) (J)

Child solicitation (IC 35-42-4-6). Child seduction (IC 35-42-4-7). Sexual misconduct with a minor as a Class A or Class B felony (IC 35-42-4-9). Incest (IC 35-46-1-3), if the victim is less than eighteen (18) years of age.

REASON FOR NO FEE REQUEST Check area that applies to your agency.
Before checking any box below read the defined Indiana Code IC 10-13-3-36 A. B. C. D. E. F. G. H. I. J. K. Has been in existence for 10 years and has a primary purpose of providing an individual relationship for a child with an adult volunteer, if the request is made as part of a background investigation of a prospective adult volunteer for the organizations; (i.e. Big Brothers & Big Sisters) Home Health Agency (Copy of license must accompany this request). Community mental retardation and other developmental disabilities centers, for purposes of IC 12-29. (Copy of CARF Certificate must be submitted with this request). Is a supervised group living facility licensed under IC 12-28-5. An area agency on aging designated under IC 12-10-1. Community action agency (as defined in IC 12-14-23-2). Owner operator of a hospice program licensed under IC 16-25-3. Community mental health center (as defined in IC-7-2-38). Department of Child Services (as defined in IC 1-13-3-27-5). Is a School Corporation, Special Education Cooperative, or Nonpublic School (as defined in IC 20-18-2-12). (1). The church or religious society is a religious organization exempt from federal income taxation under Section 501 of the Internal Revenue Code; (2). The request is made as part of a background investigation of a prospective or current adult volunteer; and (3). The employee or volunteer works in a nonprofit program or ministry of the church or religious society, including a child care ministry registered under IC 12-17.2-6.

$10.00 (

) Mark an (X) here for this request

REVIEW CHALLENGE Any person may challenge the information contained in their criminal history data file 10-13-3-31. Agencies may not request a Review Challenge. A Review Challenge may only be obtained by persons on themselves. Request by mail ­ please submit the following: a. Complete this form b. A complete set of fingerprints taken by a law enforcement agency. (Do not fold or bend card) c. $10.00 certified check or money order to State of Indiana (NO CASH OR PERSONAL CHECKS).

WARNING PENALTY FOR MISUSE
A non-criminal justice organization or individual receiving a limited criminal history may not utilize it for purposes other than those stated in the request or which deny the subject any civil right to which the subject is entitled. IC 10-13-3-27: Any person who uses limited criminal history for any purpose not specified in the request commits a Class A misdemeanor offense.

I affirm, under penalty of perjury, that the Limited Criminal History Information requested will be used as specified.

PRINT Name of Requester Signature of Requester Date

Certified check or money order only - made payable to the STATE OF INDIANA. Cash in person ONLY "NO" personal checks
Mail request to: Indiana State Police, Criminal History Limited Check P.O. Box 6188 Indianapolis, Indiana 46206-6188