Fillable Coriregulatoryviolationscomplaintform1347561307739

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Coriregulatoryviolationscomplaintform1347561307739

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BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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COMPLAINT FORM
Criminal Offender Record Information Regulatory Violations
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: 617-660-4600 | TTY: 617-660-4606 | FAX: 617-660-4613
mass.gov/cjis
Complaint Type:
CORI Regulatory Violations
Agency/Organization:Organization:
Name:
Current Address
City
State
Zip Code
Country
Last
First
Middle
Suffix
Apt/Unit
Former Address
City
State
Zip Code
Country
Apt/Unit
Phone Number 1
Phone Number 2
E-mail
E-mail
Date of Birth
Month
Day
Year
Social Security Number
Names Previously Used
LastFirst Middle Suffix
LastFirst Middle Suffix
LastFirst Middle Suffix
Description of Complaint
1. List the names and contact information for the organization you allege has violated the CORI statute or
regulations.*
2. List the name and contact information for the individual(s) that you allege has violated the CORI
statute or regulations.*
3. If known, please cite which part(s) of the CORI statute or regulation you allege has been violated.*
4. In as much detail as possible, please describe the alleged violation(s). Include in your description all
circumstances that are relevant to this complaint.*
5. State whether your are, or ever were, a party to any civil or criminal action, or action filed with an
administrative agency, related to the allegations contained in your complaint. If so, please list the parties
involved, the nature and status of the civil, criminal, or administrative agency action, the court or
administrative agency in which this action was filed, and the reference or docket number.*
6. List the name and contact information for any individual(s) that has information that may support this
complaint.*
Attach/Include Files
1. Please attach/include any documentation or correspondence you may have to support your complaint.
2. Please attach/include a legible copy of Government-issued, photo identification.
Submit Complaint
This completed complaint form and all required and available supporting documentation must be mailed
to the following:
Massachusetts Department of Criminal Justice Information Services
ATTN: Legal Department
200 Arlington Street, Suite 2200, Chelsea MA 02150
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Coriregulatoryviolationscomplaintform1347561307739

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Completed 25 October 2019

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