Form 1110-0068 Records Modification Form

Records Modification Form

FBI CJIS DIVISION

REQUIRED INFORMATION:
Master Name:_______________________________ DOB:_________________ Originating Agency:_______________
Additional Information: UCN #:________________ DOA:_____________________
MODIFIED INFORMATION: (Including any warrant#, Citation #, Agency Case #, etc)

SID

Agency Case #/OCA:

DOB:

SOC:

AKAs:

SMTs:

DOA:______________________
Arrest Charges:

Court Charges:

Dispositions:

DELETED INFORMATION: When requesting a deletion, removal or expungement for date of arrest or individual charges/disposition please use
FBI Expungement Form (FD-1114).
SID

Agency Case #/OCA:

DOA:_____________________
Arrest Charges:

Court Charges:

Dispositions:

DOB:

SOC:

AKAs:

SMTs:

(Provide State Bureau Stamp)

FD-1115
OMB 1110-0068
Rev. 02/23/2018

Social Security Account Number (SSAN): Pursuant to the Privacy Act of 1974, any Federal, state, or local government agency that requests an
individual to disclose his or her SSAN, is responsible for informing the person whether disclosure is mandatory or voluntary, by what statutory
or other authority the SSAN is solicited, and what uses will be made of it. In this instance, the SSAN is solicited pursuant to 28 U.S.C 534 and will
be used as a unique identifier to confirm your identity because many people have the same name and date of birth. Disclosure of your SSAN is
voluntary; however, failure to disclose your SSAN may affect completion or approval of your application.
PRIVACY ACT STATEMENT
Authority: The FBI's acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C.
534. Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub.L. 92-544,
Presidential Executive Orders, and federal regulations. Providing your fingerprints and associated information is voluntary; however, failure to
do so may affect completion or approval of your application.
Principal Purpose: Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint based
background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise
responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI's Next Generation
Identification (NGI) system or its successor systems (including civil, criminal, and latent fingerprints repositories) or other available records of
the employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics in
NGI after the completion of this application and, while retained, your fingerprints may continue to be compared against other fingerprints
submitted to or retained by NGI.
Routine Uses:
During the processing of this application and for as long thereafter as your fingerprints and associated information/biometrics are retained in
NGI, your information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act
of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system
and the FBI's Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental or authorized nongovernmental agencies responsible for employment, contracting, licensing, security clearances, and other suitability determinations; local,
state, tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety.
PAPERWORK REDUCTION ACT NOTICE
According to the Paperwork Reduction Act of 1995, no persons are required to provide the information requested unless a valid OMB
control number is displayed. The valid OMB control number for this information collected is 1110-0068. The time required to complete this
information collected is estimated to be 10 minutes, including time reviewing instructions, gathering, completing, reviewing and submitting
the information collection. If you have any comments concerning the accuracy of this time estimate or suggestions for reducing this
burden, please send to: Department Clearance Officer, United States Department of Justice, Justice Management Division, Policy and
Planning Staff, Washington, DC 20530.