Tx Police Clearance Form – Fill Out and Use This PDF

Dallas County Sheriff’s Department

133N. Riverfront Boulevard, LB - 31 Dallas, Texas 75207 - 4313

LUPE VALDEZ, DALLAS COUNTY SHERIFF

Attn: Semone Lilly

Telephone : 214 - 653 - 3462 Fax: 214 – 653 - 3420

Please fill out this form completely and return to this office with a cashier’s check or money order in the amount of a thirty-five ( $35.00 ) which is non-refundable, made payable to the “Dallas County Sheriff’s Office.” (NO PERSONAL CHECKS, DEBIT OR CREDIT CARDS) If you have any

questions, please contact	Semone Lilly ( 214 ) 653- 3462, 8:00 a.m. - 4:30 p.m.
STATEMENT: CLEARANCE IS FOR INFORMATION IN DALLAS COUNTY ONLY
CHECK ONE:	□ Hunting Letter
□ Visa Clearance Letter

TO: _____________________________________________________________________________________

(If request is for a Visa or Hunting Letter, the COUNTRY to which you are traveling)

□Police Clearance Letter

WHY and Who: ___________________________________________________________________________

(If request is for a POLICE CLEARANCE LETTER, please state why you need the

letter and who can verify your request, name and telephone number)

(Information will be for records in Dallas County only)

I, _________________________________, do hereby authorize Sheriff Lupe Valdez, or her designee, to

research the contents of any criminal history record that the Dallas County Sheriff’s Office may possess concerning me. I also agree to hold Sheriff Valdez, or her designee, harmless should any information given to me become distributed to others.

Name: (Please print) ________________________________________________________________________

(Last)(First)(Middle)

List any former or alias names: ________________________________________________________________

(Last)(First)(Middle)

Address: ___________________________________________________________________________________

(Street & Number)(City) (State) (Zip Code)

Date of Birth: _______________________ Race: _____________________ Sex: _______________________

Social Security No.: __________________ Driver’s License No./I.D. card: ________________ State:_________

Daytime Telephone Number: (____)____________________ Alternate Number: _(____)__________________

Signature: ______________________________________ Date: ______________________________________

Subscribed and sworn to before me this ______________ Day of ________________, Year ________________

_______________________________________________

NOTARY PUBLIC in and for the State of TEXAS

My Commission expires: __________________________

(NOTARY SEAL)

Note: This form may be mailed to the Sheriff’s Department upon completion (it must be notarized with a copy of Driver’s License or I.D. card plus a 2nd form of identification) to the address indicated above. The original form and payment MUST be sent by courier service or through the U.S. mail. If payment is made in advance, the letters may be sent to you at the address indicated on this form. If you pick up the letter and make payment in person at that time, the cashier’s window is open Monday thru Friday, from 9:00 a.m. to 4:00 p.m.) Again, only CASH, MONEY ORDER OR CASHIER’S CHECK accepted…… NO PERSONAL

CHECKS, DEBIT OR CREDIT CARDS.