Fillable Self Audit Request Form

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Self Audit Request Form

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THE COMMONWEAL
TH 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
CRIMINAL OFFENDER RECORD INFORMATION (CORI)
SELF AUDIT REQUEST FORM
Use this form for requesting a self audit under the provisions of M.G.L. c. 6, §172. Note, a self -audit is a
request for a list of CORI requests submitted by employers or for other purposes as allowed by law. If
you seek a copy of your CORI, do not submit this form. You must instead submit the personal CORI
request form or submit the request online both options available on the DCJIS website. Requests must be
mailed to the address provided above, ATTN: Self Audit.
*Last Name:
*First Name:
Former name(s) if applicable:
Please Note: You are entitled to one (1) free Self Audit every 90 days. You may request a Self
Audit at any time. Requests submitted before the 90 day waiting period must include a money
order for $25.00 made payable to the Commonwealth of Massachusetts. In addition, your
signature must be notarized. Incomplete requests will not be processed and will be returned to
the sender.
I attest under the penalties of perjury that the information provided in support of this request is
true and accurate.
Signature
Authentication of Signature by Notary Public or Correctional Facility
*Date of Birth:
*Address:
*Last 6 digits of Social Security Number:
I have never requested a Self-Audit
Date of Last Audit requested:
Phone#:
Email Address:
Date
On this _____________day of ______, 20_____, before me, the undersigned notary public, personally
appeared __________________________________(name of document signer), proved to me through
satisfactory evidence of identification, which were__________ to be the person whose name is
signed on the preceding or attached document, and acknowledged to me that (he)(she) signed
voluntarily for its stated purpose.
Notary Public
My Commission Expires
On
_______________________________________________________
_________________________
___________________
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__________________________________________________________________________________
_____________________________________
___________________________
___________________________
_______________________
__________________________________________
___________________________
___________________________
___________________________
_
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Street/P.O. Box City State Zip
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
Terms and Conditions
By 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
t
o 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 Records Review Board.
(c) CORI: Criminal
Offender Record Information.
(d) DCJIS: The Massachusetts Department of Criminal Justice Information Services.
(e) iCORI application: The internet-based system used to request and obtain CORI and
self audits, whether by electronic request or request submitted using a paper form.
(f) Requestor: A registered user of the iCORI system and any additional authorized users
for the requestor's account. Requestor, as used in these terms, 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 or a self audit from DCJIS using this form is subject to Massachusetts General Law
as well as 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), and any current or future laws applicable to the use of personal
information. Sanctions for violations of these laws include both civil and criminal penalties.
(3
) 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 CORI law, 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 under 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.
(4) The DCJIS makes every effort to ensure the accuracy and completeness of the information it provides. Neither the
DCJIS nor the CRRB shall be liable in any civil or criminal action by reason of 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.
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
(5) 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 DCJIS to
the subject's personal identifying information to ensure that 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.
(6) The requestor agrees that he/she has reviewed and understands all training materials regarding the
CORI process and CORI requirements available from the DCJIS on its website, mass.gov/cjis. The
requestor also agrees that he/she understands that reviewing and understanding the DCJIS training
materials before submitting CORI requests is a requirement of obtaining CORI from DCJIS. Requestors
are solely responsible for reviewing and understanding the training materials provided by the DCJIS.
(7) A requestor that uses CORI to commit a crime against, or to harass, another individual may be
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
DCJIS or the CRRB.
(8) 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.).
(9) No information obtained from the DCJIS regarding use of CORI or the iCORI system shall be
construed as legal advice.
(10)The DCJIS reserves the right to alter, amend, or discontinue any condition of obtaining CORI from
the DCJIS. Any such changes will appear on 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.
(11)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 judicially determined to be unlawful, void, or for any reason
unenforceable, then that provision shall be deemed severable from these Terms and Conditions and shall not affect
the validity and enforceability of the remaining provisions.
By submitting a request for CORI to the DCJIS, I affirm that I have read and understand these Terms and Conditions.
Further, I understand and 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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Self Audit Request Form

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Completed 21 February 2020

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