agency. . . .

 

agency case no. . . . .

address. . . .

 

date. . . .

 

. . . .

 

I, (Print Name) , hereby acknowledge review this date, . . . . . . . . , of a copy of a CHRI rap sheet bearing agency number . . . . . . , or SID number . . . . . . , consisting of . . . . page(s) and identified as a history of criminal offenses charged to me.

I challenge the following specific portion(s) of the CHRI as being inaccurate or incomplete:

 

 

 

. . . .

 

. . . .

 

. . . .

 

. . . .

. . . .

 

. . . .

 

. . . .

 

. . . .

. . . .

 

. . . .

 

. . . .

 

. . . .

and request modification to read:

I further request, if such modifications are determined to be valid, that all agencies who have received prior copies of the CHRI be advised of the modifications.

 

 

. . . .

(Signature of Challenger)