Dj Le 250A Form PDF Details

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Form NameDj Le 250A Form
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesdjle250a dj namerecord online form

Form Preview Example

DJ-LE-250A (Rev. 1/21)





Crime Information Bureau

Record Check Unit



PO Box 2688

Madison, WI 53701-2688 608/266-7314

A self-addressed, postage-paid envelope must accompany every inquiry. Ensure sufficient postage is included. See next page for more information/instructions.

Return request








To :

__________________________________________ Attn: ____________________________

Phone: _____________________________





City, State,









____________________________________________________________________ E-mail: _______________________________________

Requestor Type Check One

Request Purpose - Check One

Total Number of


Payment Type Check One

Government Agency$12.00*

General Information

Requests Submitted

Bill Account

General Public


Public Housing





Number #____________

Nonprofit Org.


Caregiver – General (*Add $3 DHS fee)






Public Defender (Fee Exempt)

Child Day Care - Caregiver (*Add $3 DHS fee)





Enclosed $____________





SPD # _______________________

Provide either Facility # _____________

Multiply the Search Fee (including DHS fee) times




or Certifying Agency # ______________

the Number of Requests to determine the amount to enclose

* Last Name

* First Name


* Sex * Race

*Date of Birth


Other Identifying Data

(Soc Sec Num, Maiden name)

**CIB Use Only

(Leave Blank)

*Required Data – Please type or print legibly

**CIB will indicate “No Record” or will record the State Identification Number of the corresponding record in this column. The record(s) will be attached to this form and returned.

General Instructions

Use form DJ-LE-250A to request criminal background checks on more than one individual. Use form DJ-LE-250 to request background checks on a single individual. Wisconsin Statutes 19.35(1) and

165.82provide that any person or entity may request a criminal background check. The subject of the inquiry may be any person. Wisconsin adult criminal history data held by the Crime Information Bureau is public information. Wisconsin does not release juvenile information unless statutorily authorized.

The Wisconsin Criminal History Record Request must provide:

(1)Complete the “Return request to” section.

(2)Requestor Type. Check the box for your requestor type. Nonprofit organizations must include a copy of your 501(c)3 from the IRS.. Public defenders must include your SPD number.

(3)Request Purpose. Check the “General Information” box unless you need the special processing described below. Requests received without a purpose checked will be processed as General. Caregiver Background Check processing should be used by entities or individuals required to do caregiver background checks under s. 50.065, and child care entities under s. 48.685. The caregiver background check includes a Wisconsin criminal background check, a license and registry check from the Wisconsin Department of Health Services (DHS) and a professional credential check from the Wisconsin Department of Regulation and Licensing (DRL). The results of the caregiver background check from DHS/DRL are returned separately from the Wisconsin criminal history results. Child day care providers with day care facility numbers (assigned by the Division of Children and Families (DCF)) or with certifying agency numbers (assigned by the Wisconsin Department of Workforce Development (DWD)) must check the “Child Day Care” box and provide their facility or agency number. All other entities and individuals covered by the Caregiver legislation must check the “Caregiver Background Check – General” box.

(4)Enter the number of requests.

(5)Payment Type. Wisconsin s. 165.82 requires CIB to charge a fee for background checks. If you have an account and wish to be billed, enter your account number. Account customers will be billed monthly. A check or money order must accompany all other requests. Multiply the fee amount times the number of requests to determine the amount to enclose. If appropriate, include DHS Caregiver fee in Amount Enclosed. Make checks payable to the Wisconsin Department of Justice.

(6)Enter the complete name, sex, race, and date of birth for each individual being checked. Entry of social security number is optional, but please be aware that this number is one of the unique identifiers used by the Crime Information Bureau and by the Department of Health Services. Social Security numbers help prevent incorrect matches.

(7)A self-addressed, postage-paid envelope must accompany every inquiry. Ensure sufficient postage is included. This form will be returned and stamped “No Record” if there is no public criminal information on file at CIB. The form will be accompanied by public criminal history information if a record is found. Please allow 10 business days for the CIB record check and reasonable mailing time by the postal service. Do not provide an additional envelope for Caregiver results. General Caregiver results will be returned to the address specified in the “Return request to” section and Child Daycare results will be returned to the address on file at DHS or DWD.

Mail requests to:

Crime Information Bureau, Attn: Record Check Unit, PO Box 2688, Madison, WI 53701-2688

165.82CRIMINAL HISTORY SEARCH FEE. (1) Notwithstanding ss. 19.35(3) the Department of Justice shall impose the following fees, plus any surcharge required under sub. (1m), for criminal history searches for purposes unrelated to criminal justice:

(a)For each record check, except a fingerprint card record check, requested by a nonprofit organization, $7.00.

(ag) For each record check, except a fingerprint card record check, requested by a governmental agency, $7.00. (ar) For each fingerprint card record check requested by a governmental agency, $15.

(b) For each record check by any other requestor, $7.00.

(1m) The Department of Justice shall impose a $5 surcharge if a person requests a paper copy of a criminal history search requested under sub. (1).

(2)The Department of Justice shall not impose fees for criminal history searches for purposes related to criminal justice.

1999 WISCONSIN ACT 9 This act authorizes the Department of Health Services to impose a fee for caregiver checks submitted to that agency. This fee has been set at $3 and is effective April 1, 2000. The Department of Justice has agreed to collect this fee for DHS.

Requestor Type Category Definitions

Nonprofit Organization – An organization in which no part of the income is distributable to its members, directors or officers. Record check requests submitted to the Crime Information Bureau by nonprofit organizations must include a copy of their 501{c}{3} ruling from the Internal Revenue Service.

Governmental Agency – A federal, state, county or municipal governing body created by constitution, state, code, charter, ordinance, rule or order and any formally constituted subunit or agency thereof. This category includes public school districts.

Any Other Requestor – Includes the general public, and individual, agency or organization that does not meet the definition of governmental agency, nonprofit organization or a criminal justice agency involved in the administration of criminal justice.

How to Edit Dj Le 250A Form Online for Free

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Please provide the next details to fill out the Dj Le 250A Form PDF:

step 1 to completing Dj Le 250A Form

You have to type in the necessary details in the Required Data Please type or, and CIB will indicate No Record or field.

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