Fill - Free fillable Advocate Or Designated Representative Request Form (1) (Commonwealth of Massachusetts) PDF form

THE COMMONWEALTH OF MASSACHUSETTS

EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY

Department of Criminal Justice Information Services

200 Arlington Street, Suite 2200, Chelsea, MA 02150

TEL: 617-660-4640 | TTY: 617-660-4606 | FAX: 617-660-5973

MASS.GOV/CJIS

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1

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CriminalOffenderRecordInformation(CORI)

AdvocateorDesignatedRepresentativeRequestForm

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UsethisformforrequestingCORIundertheprovisionsofM.G.L.c.6,§172.Anadvocateand/ordesignatedrepresentative

maysubmitthisformforthepurposeofrequestingCriminalOffenderRecordInformation(CORI)onbehalfofaclient.The

clientmustsignthisforminordertodemonstratethathe

orsheisproviding theadvocateordesignatedrepresentative

withpermissiontoaccesstheCORI.Thissignaturemustalsobeauthenticatedbyanotarypublic.

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AmoneyorderorbankissuedCashier’sorTreasurer’scheckintheamountof$25.00madeouttotheCommonwealthof

Massachusettsmustbesubmittedwiththisform.Pleasenotethatthesearetheonlyacceptableformsofpayment.Do

notsendcash,personalchecks,orbusinesschecks.

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Requests mustbemailed, along with theaccompanying paymentorindigency waiver,tothe address provided above,

ATTN:CORIUnit.

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REQUESTINFORMATION

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* IsthesubjectofthisCORIrequestindigent? ☐Yes ☐No

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Pleasenote:Youwillneedtosubmitanindigencywaiverifthesubjectisindigent.Theindigencywaiverformcanbe

foundathttp://www.mass.gov/eopss/docs/chsb/affidavit‐of‐indigency.pdf.

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REQUESTORINFORMATION

Pleasecompletethissectionusingtheinformationofthepersonsubmittingthisrequest.Thefieldsmarkedwithan

asterisk(*)arerequiredfields.

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* Iamsubmittingthisrequestasa(n): ☐Advocate ☐DesignatedRepresentative

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* FirstName:________________________________________________________ MiddleInitial: _________________

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* LastName:________________________________________________ _________ Suffix(Jr.,Sr.,etc.): _____________

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* DateofBirth: _____________________________________________________________________________________

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* LastSIXdigitsofyourSocialSecurityNumber:______‐‐____________ ☐IdonothaveaSocialSecurityNumber

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* PhoneNumber: _______________________________________________________ ____________________________

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 EmailAddress: ____________________________________________________________________________________

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MailingAddress

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* StreetAddress:____________________________________________________________________________________

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 Apt.#orSuite: _____________ *City:__________________________ *State: ________ *Zip:_______________

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Ifyouaresubmittingthisrequestonbehalfofanorganization,pleasecompletethesectionsbelow.

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* OrganizationName: __________________________ _____________________________________________________

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* StreetAddress:____________________________________________________________________________________

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 Apt.#orSuite: _____________ *City:__________________________ *State: ________ *Zip:_______________

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* PhoneNumber: __________________________________________________________________________________

THE COMMONWEALTH OF MASSACHUSETTS

EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY

Department of Criminal Justice Information Services

200 Arlington Street, Suite 2200, Chelsea, MA 02150

TEL: 617-660-4640 | TTY: 617-660-4606 | FAX: 617-660-5973

MASS.GOV/CJIS

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2

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SUBJECTINFORMATION

PleasecompletethissectionusingtheinformationofthepersonwhoseCORIyouarerequesting.

Thefieldsmarkedwithanasterisk(*)arerequiredfields.

 

* FirstName:________________________________________________________ MiddleInitial: _________________



* LastName:________________________________________________ _________ Suffix(Jr.,Sr.,etc.): _____________

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 FormerLastName1: _______________________________________________________________________________

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 FormerLastName2: _______________________________________________________________________________

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 FormerLastName3: _______________________________________________________________________________

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 FormerLastName4: _______________________________________________________________________________

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* DateofBirth(MM/DD/YYYY): ______________ ProbationCentralFile(PCF)Number(s)(ifknown): ________________

* LastSIXdigitsofSocialSecurityNumber: ______‐‐______ ______ ☐NoSocialSecurityNumber

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 Father’sFullName: ________________________________________________________________________________

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 Mother’sFullName: _______________________________________________________________________________

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THE COMMONWEALTH OF MASSACHUSETTS

EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY

Department of Criminal Justice Information Services

200 Arlington Street, Suite 2200, Chelsea, MA 02150

TEL: 617-660-4640 | TTY: 617-660-4606 | FAX: 617-660-5973

MASS.GOV/CJIS

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3

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AUTHORIZATIONOFPERSONNAMEDINTHECRIMINALRECORD

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I,_________________________________________,authorize ___________________________________________to

 (SubjectofCORIRequest) (NameofRequestor)

accessallmyavailableCriminalOffenderRecordInformation(CORI)fromtheMassachusettsDepartmentofCriminal

JusticeInformationServices(DCJIS).Iauthorizethisdisclosuretotheabovenamedadvocateordesignated

representativeforthesolepurposeofassistingmewithinterpretingtheCORIformyownpersonaluse.Iunderstand

thatit

isunlawfulforanindividualtorequiremetoprovidemyownCORIandtheCORIresultsarevoluntarilybeing

providedtotheabovenamedadvocateordesignatedrepresentativeatmyrequest.

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___________________________________________________________________ ____________________________

SignatureofIndividualAuthorizingCORIRequest Date

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AuthenticationofSignature

PleasenotethatALLfieldsinthissectio nmustbecompletedbytheNotaryPublic.

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On this ______ day of ___________, 20____, befor e me, the undersigned Notary Public, personally appeared

_______________________ (name of CORI subject) and proved to me through satisfactory evidence of identification,

whichwas______________________(Ex:Driver’slicense,passport,etc.),tobethepersonwhosenameissignedonthe

precedingorattached

document,andacknowledged tomethat(he)(she)signeditvoluntarilyforitsstatedpurpose.

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_____________________________________________________ _________________________________

SignatureofNotaryPublic(No tarystamporsealisalsorequired) DatemyCommissionexpires

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Terms and Conditions

By submitting a request for CORI using this form, the Requestor agrees to be bound by these terms and

conditions and any and all other guidelines, disclaimers, rules, and privacy statements within this agreement,

collectively referred to as "Terms and Conditions." All Terms and Conditions contained herein apply only to

obtaining information from the DCJIS.

1. As referenced in these terms and conditions, the terms below shall have the following meanings:

a. CRA: Consumer Reporting Agency

b. CRRB: The Criminal Record Review Board

c. CORI: Criminal Offender Record Information

d. DCJIS: The Massachusetts Department of Criminal Justice Information Services

e. iCORI service: The internet-based service used to request and obtain CORI and self audits.

f. Requestor: A registered user of the iCORI service and any additional authorized users for the

requestor's account. Requestor, as used in these terms, also includes Consumer Reporting

Agency requestors. Requestor, as used in these terms, also includes any individual who requests

or obtains CORI or a self-audit report from DCJIS using a paper form.

2. Obtaining CORI from DCJIS by using this form is subject to Massachusetts General Law and to Federal

law, including, but not limited to, M.G.L. c.6, §§ 167-178B (the CORI Law), M.G.L. c. 66, § 10 (the

Public Records Law), M.G.L. c. 266, § 120F (Unauthorized use of a computer), and any current or

future laws applicable to the use of computer systems or personal information. The penalties for

violations of these laws include both civil and criminal penalties.

3. A requestor may only request the level of CORI access authorized by statute or the DCJIS for the type

of request being submitted. A requestor who submits a CORI request using an access level higher than

that authorized for the type of request being submitted will be in violation of the CORI law and DCJIS

regulations and may be subject to both civil and criminal penalties.

4. An individual or entity who knowingly requests, obtains, or attempts to obtain CORI or a self-audit from

the DCJIS under false pretenses, or who knowingly communicates, or attempts to communicate, CORI

to any individual or entity except in accordance with the CORI law and DCJIS regulations, or who

knowingly falsifies CORI or any records relating thereto, or who requests or requires a person to provide

a copy of his or her CORI except as authorized pursuant to M.G.L. c. 6, § 172, shall, for each offense, be

punished by imprisonment in a jail or house of correction for not more than one year or by a fine of not

more than $5,000.00. In the case of an entity that is not a natural person, the amount of the fine may not

be more than $50,000.00. In the case of such a violation involving juvenile delinquency records, an

individual or entity shall, for each offense, be punished by imprisonment in a jail or house of correction

for not more than one year or by a fine of not more than $7,500.00. In the case of an entity that is not a

natural person, the amount of the fine may not be more than $75,000.00.

5. Neither the DCJIS nor the CRRB shall be liable in any civil or criminal action due to any CORI or self-

audit report that is disseminated by the DCJIS or the CRRB, including any information that is false,

inaccurate, or incorrect, because it was erroneously entered by the court or the Office of the

Commissioner of Probation.

6. CORI results are based on an exact match of the information provided by the requestor to information as

it appears in the CORI database. Requestors are responsible for providing accurate information for the

subject requested. In addition, it is the requestor's responsibility to compare the CORI or self-audit

results received from the iCORI service to the subject's personal identifying information to ensure that

the results match this information. The DCJIS is not liable for any errors or omissions in the CORI

results based on a requestor's submission of inaccurate, incorrect, or incomplete subject information.

Furthermore, NO REFUNDS of CORI fees will be provided because of data entry errors or other errors

or omissions made by the requestor.

7. Each requestor who submits 5 or more background checks annually must have a written CORI policy.

Each requestor is responsible for adopting its own CORI policy. The DCJIS publishes a model CORI

policy on its website that may be adopted for use by requestors. If this requirement applies to a

requestor, the requestor agrees that at the time of submission of any CORI request, it has adopted a

CORI policy.

8. The requestor agrees that he/she has reviewed and understands all training materials regarding the CORI

process and CORI requirements available from the DCJIS. Requestors are solely responsible for

reviewing and understanding the training materials provided by the DCJIS.

9. Requestors who seek to receive the standard or required level of access to CORI for employment,

housing, licensing, or volunteer purposes must ensure that the following are completed prior to

submitting a CORI request:

a. Completion of a CORI Acknowledgement Form for each subject to be checked;

b. Verification of the identity of the subject using an acceptable for of government issue

identification;

c. Obtaining the subject's signature on the CORI Acknowledgement Form;

d. Signing and dating the CORI Acknowledgement Form certifying that the subject was properly

identified; and

e. Confirming that the requestor is in compliance with all applicable laws and regulations.

10. All requestors, including those that request CORI through a CRA, must comply with 803 C.M.R. 2.00

and, if applicable, 803 C.M.R. 5.00. In addition, CRAs are also responsible for ensuring compliance

with the Fair Credit Reporting Act and with DCJIS regulation 803 CMR 11.00.

11. A requestor that uses CORI to commit a crime against, or to harass, another individual is subject to the

criminal penalties set forth in M.G.L. c. 6, §178 ½, including imprisonment in a jail or house of

correction for not more than one year and a fine of not more than $5,000.00. The DCJIS and the CRRB

disclaim any liability for the improper use or dissemination of information obtained through the iCORI

service.

12. Requestors are subject to audit at any time by the DCJIS and may be asked to produce documentation to

demonstrate compliance with these provisions and with DCJIS regulations (803 CMR 2.00-11.00 et

seq.).

13. No information obtained from the iCORI service or from DCJIS personnel regarding use of the iCORI

service shall be construed as legal advice.

14. The DCJIS reserves the right to alter, amend, or discontinue any feature of the iCORI service or the

conditions of its use at any time. Any such changes will be announced on the iCORI service and/or the

DCJIS website in advance. The user is subject to the terms of use in effect at the time of his/her

agreement. The DCJIS and the CRRB shall not be liable for any damages associated with use of this

site.

15. These Terms and Conditions are governed by, and construed in accordance with, the laws of the

Commonwealth of Massachusetts and the laws of the United States, without giving effect to any

principles of conflicts of law. If any provision of these Terms and Conditions is determined to be

unlawful, void, or for any reason unenforceable, then that provision shall be considered void. The

remaining provisions shall remain valid and enforceable.

16. By submitting a request for CORI to the DCJIS, I affirm that I have read and understand these Terms

and Conditions. Further, I acknowledge, agree to, and am bound by, these Terms and Conditions, as well

as by M.G.L. c. 6, §§ 167-178B, inclusive, and 803 CMR 2.00-11.00, inclusive.

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Advocate Or Designated Representative Request Form (1) (Commonwealth of Massachusetts)

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