CR-2 rev. 09/07/2007
This local Criminal History name search report includes only those misdemeanor convictions after 1985 which are
not reportable to State Police. It does NOT include felonies or reportable misdemeanor convictions. For a complete
Criminal History Record, contact the VIRGINIA STATE POLICE.
To request by mail, address to: City of Richmond, Police Department
Central Records Unit
200 W. Grace Street
Richmond, VA 23220-5018
1.
PRINT LAST NAM
FIRST NAME
CITY/COUNTY OF BIRTH STATE/COUNTRY OF BIRT
PRINT COMPLETE CURRENT ADDRES
I hereb
ive consent and authorize the Richmond Police De
artment to search its files for an
histor
of non-re
ortable local
misdemeanor conviction and re
ort the results of such search to the a
ent or individual authorized in this document to receive same.
Signature of person whose history is requested Date
State of City/County o
to wit Subscribed and sworn to before me
this day of My Commission expires
.
Signature of Notary Public
2.
Mail completed history report to: NAME:
STREET ADDRESS:
CITY/STATE/ZIP CODE:
As
rovided for in Section 19.2-389, Code of Vir
inia, I hereb
re
uest the non-re
ortable misdemeanor histor
of the individual named in section 1
above and swear or affirm that I have the consent of the
erson to obtain his/her record and will not further disseminate the information received
exce
t as
rovided b
law.
Signature of person making this request. Date
State of City/County o
to wit Subscribed and sworn to before me
this day of My Commission expires
.
Signature of Notary Public
Check here if an additional co
is to be
rovided to the individual named in it, and attach a se
arate check or mone
order in the amount of $1.00.
This report reflects only offenses not
required to be reported to the Central Criminal Records Exchange of the Virginia State Police.
RECORD(S) FOUND. NO SUCH RECORD OF NON-REPORTABLE MISDEMEANORS EXISTS.
Date By:
*
This re
ort lists convictions onl
- it does not rule out the existence of an arrest or a char
e for which court dis
osition is
endin
.
*If mailed, this form must be notarized by a notary public in the space provided below, to attest to the identity of the requestor. A certified check, money order, or
company check for $5.00 must accompany this request before a file check will be initiated. No personal checks accepted .
(SEE ATTACHED)
DOB
SOCIAL SECURITY NUMBE
AFFIDAVIT FOR RELEASE OF INFORMATION
MIDDLE MAIDEN SEX
RICHMOND POLICE DEPARTMENT
20 20
This is NOT a complete Criminal History Record
NON-REPORTABLE MISDEMEANOR CONVICTION HISTORY
20
PERSON WHOSE MISDEMEANOR HISTORY IS REQUESTED
20
AGENCY, INDIVIDUAL, OR AUTHORIZED AGENT MAKING REQUEST
RAC
