Fillable Improper Access Dissemination Of Cori (Commonwealth of Massachusetts)

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Improper Access Dissemination Of Cori (Commonwealth of Massachusetts)

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COMPLAINT FORM
Improper Access To, and/or Dissemination Of, Criminal Offender Record Information
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:
Improper Access and/or Dissemination of CORI
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
Title
Description of Complaint:
1. Describe the Criminal Offender Record Information (CORI) that was allegedly improperly accessed
and/or disseminated.*
2. State when you believe your CORI was improperly accessed and/or disseminated. Please include all
relevant dates.*
3. State whom you believe improperly accessed and/or disseminated your CORI. Please provide contact
information for this individual, if known.*
4. State to whom you believe your CORI was improperly accessed and/or disseminated. Please provide
contact information, if known, for this/these individual(s).*
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.*
7. In as much detail as possible, describe how your information was allegedly improperly accessed and/or
disseminated.* (attach additional sheets if necessary)
By signing below, I attest that the information provided in this complaint, and in support thereof, is
true to the best of my knowledge.
Signed under the penalties of perjury.
Name Signature Date
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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Improper Access Dissemination Of Cori (Commonwealth of Massachusetts)

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Completed 27 July 2020

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