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
MASS.GOV/CJIS
OnBehalfOf/ChildCareProvider
CriminalOffenderRecordInformation(CORI)RequestForm
UsethisformforrequestingCORIunderthe provisionsofM.G.L.c.6,§172.Thisformmaybesubmittedbyparentsor
legalguardiansofmi norchildren(aged17andunder)thatseektoscreenprospectivechildcareproviders.Abankcheck
ormoneyorderintheamountof$25.00
madeouttotheCommonwealthofMassachusettsmustbesubmittedwiththis
form.Pleasenotethatthesearetheonlyacceptableforms ofpayment.Donotsendcash,personalchecks,orbusiness
checks.Mailrequestsandaccompanyingpaymentorindigencywaivertotheaddressprovidedabove,ATTN:CORIUnit.
REQUESTINFORMATION
* IsthethepersononwhosebehalfyouarerequestingtheCORIindigent? YesNo
Pleasenote:YouwillneedtosubmitanindigencywaiverifthepersononwhosebehalfyouarerequestingtheCORIis
indigent.
Theindigencywaiverformcanbefoundathttp://www.mass.gov/eopss/docs/chsb/affidavitofindigency.pdf.
RequestorDetails
Completethissectionwithyourinformation. Itemsmarkedwithanasterisk(*)MUSTbecompleted.
* FirstName: _______________________________________________________ MiddleInitial: _________________
* LastName: _______________________________________________________ Suffix(Jr.,Sr.,etc): _____________
* DateofBirth(MM/DD/YYYY):_____________________ LastSIXdigitsofSocialSecurityNumber: ____‐‐________
* PhoneNumber: __________________________________ EmailAddress: ___________________________________
MailingAddress
* StreetAddress:____________________________________________________________________________________
* Apt.#orSuite:_______________ *City:__________________________ *State: ________ *Zip:_______________
OnBehalfOf
CompletethissectionwiththeinformationofthepersononwhosebehalfyouarerequestingtheCORI.
* FirstName: _______________________________________________________ MiddleInitial: _________________
* LastName: _______________________________________________________ Suffix(Jr.,Sr.,etc): _____________
* DateofBirth(MM/DD/YYYY):_____________________ LastSIXdigitsofSocialSecurityNumber: ____‐‐________
* PhoneNumber: __________________________________ EmailAddress: ___________________________________
MailingAddress
* StreetAddress:____________________________________________________________________________________
* Apt.#orSuite:_______________ *City:__________________________ *State: ________ *Zip:_______________

SubjectDetails
CompletethissectionwiththeinformationofthepersonwhoseCORIyouarerequesting.
* FirstName: _______________________________________________________ MiddleInitial: _________________
* LastName: _______________________________________________________ Suffix(Jr.,Sr.,etc): _____________
FormerLastName1: _______________________________________________________________________________
FormerLastName2: _______________________________________________________________________________
FormerLastName3: _______________________________________________________________________________
FormerLastName4: _______________________________________________________________________________
* DateofBirth(MM/DD/YYYY):_____________________ LastSIXdigitsofSocialSecurityNumber: ____‐‐________
Father’sFullName: ________________________________________________________________________________
Mother’sFullName: __________________________ _____________________________________________________
ConsentofChildCareProvider
Iunderstandthatparent(s)orguardian(s)whoareinterestedinscreeningcurrentorprospectivechildcareproviderswho
would have direct and unmonitored contact with their children have been authorized by the Department of Criminal
JusticeInformationServicestohave accesstoallconvictionandpendingcasecriminalhistoryinformation, pursuant
to
M.G.L.c.6§172(c).Ialsounderstandthatacriminalrecordcheckwillbeperformedonmeandthattheresultsmaynot
befurtherdisseminatedbytherequestingparent(s)orguardian(s).
Signedunderthepains andpenaltiesofperjury,onthis_________dayof__________________________,20_______.
___________________________________________________________________ ____________________________
Signatureof(Prospective)ChildCareProvider Date
AuthenticationofSignature
PleasenotethatALLfieldsinthissectio nmustbecompletedbytheNotaryPublic.
On this ______ day of ___________, 20____, before me, the undersigned Notary Publi c, personally appeared
_______________________ (name of CORI subject) and proved to me through satisfactory evidence of identifi cation,
whichwas______________________(Ex:Driver’slicense,passport,etc.),tobethepersonwhosenameissignedonthe
precedingorattached
document,andacknowledged tomethat(he)(she)signeditvoluntarilyforitsstatedpurpose.
_____________________________________________________ _________________________________
SignatureofNotaryPublic(No tarystamporsealisalsorequired) DatemyCommissionexpires

Parent/Guardian’sAgreementofUnderstanding
I,________________________________,underoathandaffirmation,statethatIhavehired,orintendtohire,the
abovenamedchildcareproviderwhowillhavedirectandunmonitoredcontactwithmychildren.Iunderstandthatany
personwhowillfullyrequests,obtains,orseekstoobtaincriminaloffenderrecordinformation(CORI)under
false
pretenses,orwhowillfullycommunicates,orseekstocommunicate,CORItoanyagencyorperson,exceptin
accordancewiththeprovisionsofM.G.L.c.6,ss167178B,shall,foreachoffense,befinednotmorethanfivethousand
dollars,orimprisonedinajailorhouseofcorrectionfor
notmorethanoneyear,orboth.
Signedunderthepains andpenaltiesofperjury,onthis_________dayof__________________________,20_______.
___________________________________________________________________ ____________________________
SignatureofParent/Guardian Date
AuthenticationofSignature
PleasenotethatALLfieldsinthissectio nmustbecompletedbytheNotaryPublic.
On this ______ day of ___________, 20____, before me, the undersigned Notary Publi c, personally appeared
_______________________(nameofCORIrequestor)andprovedtomethroughsatisfactoryevidenceofidentification,
whichwas______________________(Ex:Driver’slicense,passport,etc.),tobethepersonwhosenameissignedonthe
precedingorattached
document,andacknowledged tomethat(he)(she)signeditvoluntarilyforitsstatedpurpose.
_____________________________________________________ _________________________________
SignatureofNotaryPublic(No tarystamporsealisalsorequired) DatemyCommissionexpires
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.