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Indiana State Police
Criminal History Information
Limited Criminal History
& Fee Exemption
ID Billing Number
Or Customer ID #
* This agency is requesting disclosure of your Soc ial Security Number in ac cordance with IC 4-1-8-1; disclosure is voluntary and you will n ot be penali zed for refusa l.
PLEASE TYPE OR PRINT ALL INFORMATION.
RECORD CHECK ON:
\ \ \ \ \ \
Social Security Number*
\ \ \ \ \ \
Place of Birth
Date of Birth MM / DD / YYYY
M = Male
F = Female
W = White B = Black
U = Unknown M = Multi Racial
I = American Indian Alaskan
A= Asian / Pacific Islander
REASON FOR SEARC H
Private Adoption, Employment,
Licensing (type), et c.
(where this response will be sent)
Mailing Address (number and street)
City, State, ZIP Code
Daytime Telephone Number
(1) Has applied for employment with a non-criminal justice organization or individual;
Has applied for a license or is maintaining a license; and has provided criminal history data as required by law to be
provided in connection with the license.
Employment with a state or local governmental entity.
Is a candidate for public office or a public official;
Is in the process of being apprehended by a law enforcement agency;
Is placed under arrest for the alleged commission of a crime;
Has charged that his rights have been abused repeatedly by criminal justice agencies;
Is the subject of judicial decision or determination with respect to the setting of bond, plea bargaining, senten cing,
Has volunteered services that involve contact with, care of, or supervision over a child who is being placed,
matched, or monitored by a social services agency, or a nonprofit corporation;
Is employed by an entity that seeks to enter into a contract with a public school (as defined in IC 20-10.1-1-2) or a
non-public school (as defined in IC 20-10.1-1-3), if the subject of the request is expected to have direct, ongoing
contact with school children within the scope of the subject's e mployment;
Has volunteered services at a public school (as defined in IC 20-10.1-1-2) or non-public school (as defined in IC
20-10.1-1-3) that involve contact with, care of, or supervision over a student enrolled in the school; Student Teacher
Is being investigated for welfare fraud by an investigator of the Division of Family Resources, or a county office of
the Division of Family Resources;
Is being sought by the parent locator service of the Child Support Bureau of the Division of Family Resources;
Is or was required to register as a sex and violent offender under IC 5-2-12; or
Has been convicted of any of the following:
(A) Rape (IC 35-42-4-1), if the victim is less than eighteen (18) years of age.
(B) Criminal deviate conduct (IC 35-42-4-2), if the victim is less than eighteen (18) years of age.
(C) Child molesting (IC 35-42-4-3).
(D) Child exploitation (IC 35-42-4-4(b)).
Limited Criminal History Information – Reason for Request
The cost is $7.00. Mark an “X” in one box below for this request.
Certified check or money order must be enclosed if request is mailed.
Money orders will be accepted in person.
State Form 8053 (R11 / 4-14) Stock #575
Approved by State Board of Accounts, 2014
(E) Possession of child pornography (IC 35-42-4-4(c).
(F) Vicarious sexual gratification (IC 35-42-4-5).
(G) Child solicitation (IC 35-42-4-6).
(H) Child seduction (IC 35-42-4-7).
(I) Sexual misconduct with a minor as a Class A or Class B felony (IC 35-42-4-9).
(J) Incest (IC 35-46-1-3), if the victim is less than eighteen (18) years of age.
(K) Attempt under IC 35-41-5-1 to commit an offense listed in clauses (A) through (J).
(L) Conspiracy under IC 35-41-5-2 to commit an offense listed in clauses (A) through (J).
(M) An offense in any other jurisdiction in which the elements of the offense for which the conviction
was entered are substantially similar to the elements of an offense described under clauses (A)
is identified as a possible perpetrator of child abuse or neglect in an assessment conducted by the department of
child services under IC 31-33-8; or
(A) a parent, guardian or custodian of a child; or
(B) an individual who is at least eighteen (18) years of age and resides in the home of the parent, guardian or
custodian; with whom the department of child services or a county probation department has a case plan,
dispositional decree, or permanency plan approved under IC 31-34 or IC 31-37 that provides for
reunification following an out-of-home placement.
Before checking any box below read the defined Indiana Code IC 10-13-3-36
A. Has been in existence for ten (10) years and has a primary purpose of providing an individual relationship
for a child with an adult volunteer, if the request is made as part of a background investigation of a
prospective adult volunteer for the organizations; (i.e. Big Brothers & Big Sisters)
Home Health Agency (Copy of license must ac company this request).
Community mental retardation and other devel opmental disabilities centers, for purposes of IC 12-29.
(Copy of CARF Certificate must be submitted with this request).
Is a supervised group living facility licensed under IC 12-28-5.
An area agency on aging desig nated under IC 12-10-1.
Community action agency (as defined in IC 12-14-23-2).
Owner operator of a hospice program licensed under IC 16-25-3.
Community mental health cent er (as defined in IC-7-2-38).
Department of Child Services (as defined in IC 1-13-3-27-5).
Is a School Corporation, Special Education Cooperative, or Nonpublic School (as defined in IC 20-18-2-12).
(1) The church or religious society is a religious organization exempt from federal income taxation under
Section 501 of the Internal Revenue Code;
(2) The request is made as part of a background investigation of a prospective or current adult volunteer;
(3) The employee or volunteer works in a nonprofit program or ministry of the church or religious society,
including a child care ministry registered under IC 12-17.2-6.
WARNING PENALTY FOR MISUSE
A non-criminal justice organization or individual receiving a limited criminal history may not utilize it for purposes other than those
stated in the request or which deny the subject any civil right to which the subject is entitled. IC 10-13-3-27: Any person who uses
limited criminal history for any purpose not specified in the request commits a Class A misdemeanor offense.
I affirm, under penalty of perjury, that the Limited Criminal History Information requested will be used as
PRINT Name of Requester
Signature of Requester Date (month, day, year)
We accept certified checks and money orders in person only. “NO” per sonal checks.
All checks made payable to the STATE OF INDIANA.
Indiana State Police, Criminal History Limited Check
P.O. Box 6188
Indianapolis, Indiana 46206-6 188
REASON FOR NO FEE REQUEST