Request for Investigative Information from a Criminal Justice Agency

This form is to be used when requesting access to investigative information from a criminal justice agency under the Pennsylvania Criminal History Record Information Act (CHRIA). Only a direct victim of crime who intends to sue or has filed suit, or a defendant in a civil lawsuit in which a direct victim is a party, or the personal representative of such a victim or civil defendant, may obtain access to this information.

Criminal Justice Agency from which investigative information is requested:

Agency Name

Agency Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of Requester

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Status of Requester:

Direct victim of crime

Personal representative of a direct victim of crime

Defendant in a civil lawsuit in which direct victim of crime is a party

Personal representative of a defendant in a civil lawsuit in which direct victim of crime is a party

Name of defendant in criminal case

First Last

Instructions:
Press the

button to create a new lines.

Name of law enforcement agency/ies involved in the investigation

Caption and docket number, if known, of criminal case for which Requester is seeking investigative information

Court, caption, and docket number for civil case for which investigative information is sought

Please indicate why you are requesting the dissemination of investigative information:

The requested information is directly related to a civil action pending in a court in this Commonwealth.

The requested information is material and necessary to the investigation or preparation of a civil action in this Commonwealth.

Please identify or describe the information sought with sufficient specificity to enable the criminal justice agency possessing the information to ascertain what information is being requested.

Please explain how the information sought is directly related to a pending civil action or material and necessary to the investigation or preparation of a civil action.

The information provided and the facts recited in this Request for Investigative Information from a Criminal Justice Agency are true and correct to the best of my knowledge and belief. This statement is made with knowledge that a false statement is punishable by law under 18 Pa. C.S. § 4904(b) (unsworn falsification to authorities).

Signature

Date

I understand that:

Despite this request, dissemination of investigative information may be denied because it is otherwise nondiscoverable or privileged for reasons set forth in Subchapter F.1 of the Criminal History Record Information Act.
Investigative information obtained through this Request may be used only in connection with an actual or potential civil action directly relating to the investigative information.
The use of investigative information obtained under Subchapter F.1 of the Criminal History Record Information Act to harass, intimidate, or threaten another person constitutes a misdemeanor of the second degree.

This statement is made with knowledge that a false statement is punishable by law under 18 Pa. C.S. § 4904(b) (unsworn falsification to authorities).

Signature

Date

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Request for Investigative Information from a Criminal Justice Agency