EVT0009616-Vendor_Company_Background_Information_Form.pdf

Vendor (COMPANY) Background Information

Read the complete form before filling it out. This form must be completely filled out: typed or printed legibly in ink. In the event the space provided for information is insufficient, attach additional sheets. Please include a copy of your current Driver’s License when you return this to the Lottery.

Review the attached information regarding obtaining fingerprinting. Your fingerprints can be obtained at most law enforcement agencies including the Kansas Bureau of Investigation.

All applicants should be aware that prior to appointment, Kansas Statute requires an extensive and detailed background investigation be conducted by the Kansas Lottery Security Division or Agents of the Kansas Bureau of Investigation or the Kansas Highway Patrol. As part of that investigation, you may be asked to furnish additional information, records or documents as determined by the assigned investigator or agency.

Return completed form to: The Kansas Lottery

Security Division 128 N. Kansas Avenue Topeka, Kansas 66603

Vendor Name and Address and Phone:

Rev 2015

PERSONAL INFORMATION

Full Name (First, Middle, Last) Social Security Number

Date of Birth (mm/dd/yyyy) Place of Birth

Business Telephone# Residence Telephone# Cell Phone # Email Address

Drivers License Number & State of Issuance Have you ever held a drivers license in another state(s)? If so, please provide details:

List any other names you are known by or have been known by, and dates used:

RESIDENCE

List all present and previous addresses, both temporary and permanent. If exact address cannot be remembered, provide city and state.

Present:

Address/City/State/Zip From To Own ____ Rent ____

(If applicable) Landlord Name and Address/City/State/Zip Telephone Number

Previous:

Address/City/State/Zip From To Own ____ Rent ____

Telephone Number (If applicable) Landlord Name and Address/City/State/Zip Previous:

Address/City/StateZip From To Own ____ Rent ____

(If applicable) Landlord Name and Address/City/State/Zip Telephone Number

EDUCATION

List your post-high school educational experience in reverse chronological order. Please include any trade, technical, or extended professional training:

Institution: Dates Attended:

Institution Address:

Program of study or degree received:

Institution: Dates Attended:

Institution Address:

Program of study or degree received:

Institution: Dates Attended:

Institution Address:

Program of study or degree received:

EMPLOYMENT

List all present and previous employment information in reverse chronological order. If necessary, include additional pages. Please provide as many details as possible, and include any service as an officer or director of any company, corporation, or organization, regardless of whether compensation was received as a result of those duties.

Present Employer:

Company Name Address/City/State/Zip Telephone Number

Position/Title Employment Dates From To

Previous Employer:

Company Name Address/City/State/Zip Telephone Number

Position/Title Employment Dates From To

Previous Employer:

Company Name Address/City/State/Zip Telephone Number

Position/Title Employment Dates From To

Previous Employer:

Company Name Address/City/State/Zip Telephone Number

Position/Title Employment Dates From To

GENERAL

List any state or jurisdiction where you hold or have held a gaming license, or were subject to a background investigation for the purpose of determining suitability to provide products or services in the gaming industry:

Have you ever had a professional license, security clearance, or certificate which was suspended, revoked or denied? If yes, please explain:

List all business or professional organizations to which you belong or have belonged in the past five years:

Organization Date

Organization Date

Organization Date

CRIMINAL HISTORY

Do you have any criminal charges pending in any jurisdiction? If yes, please explain:

Are you currently on parole or probation? If yes, explain. (Include dates, location, original charges, court, and supervising officer):

Have you or any company you have been associated with been the subject of any criminal investigation or inquiry? If yes, please explain:

List all criminal offenses for which you have been convicted. Include DUI’s, serious or habitual traffic offenses and nolo contendere pleas.

Charge Date of offense or charge City and State Court Final Disposition

Charge Date of offense or charge City and State Court Final Disposition

Charge Date of offense or charge City and State Court Final Disposition

CIVIL COURT ACTION

List all occasions within the last three years, in which you have been a participant (plaintiff, defendant, witness) in a civil court action. Please include divorce and small claims proceedings.

Nature of case:

Date of case: City, State & Court:

Disposition of case:

Nature of case

Date of case: City, State & Court:

Disposition of case:

GAMBLING

Have you ever been arrested for illegal gambling activities? If yes, please explain:

Do you currently owe any debt as a result of gambling? If yes, please explain:

Do you have any business and/or financial interest(s) with any organization involved in gaming or the lottery? If yes, please explain:

Have you, either individually or as a member of any group, ever been denied or withdrawn a gaming license or gaming license application? If yes, please provide details:

CHARACTER AND FINANCIAL DISCLOSURE FORM

FOR ALL VENDORS

THE VENDOR SHALL PROVIDE THE FOLLOWING INFORMATION:

1. Name of business:

2. Type of legal entity:

3. Address:

4. Telephone number:

5. (a) List any trade names or assumed names used:

(b) List all states where these names are used:

6. Attach a copy of vendor’s latest financial statement.

I, ________________________________, hereby authorize the Kansas Lottery or its designee to conduct a background investigation using the information contained in the Character and Financial Forms attached to the RFP and such other evidence which may be found from said investigation to determine the criminal and financial/credit history of the above-named business. I hereby release all organizations, individuals, agencies, and their employees and agents, from any liability that may result from their furnishing such information.

Signature and Date

Printed Name

Title

Rev 2015 flyntzcj Text Box

FINANCIAL

List any corporation, partnership, proprietorship, trust, joint venture, and every other business interest, including land used for income in which either you or your spouse:

Own a controlling interest;

Own 5% or more of said entity; or Are an officer, director, partner, or proprietor

Business interest includes, among other things, property held for rental, farming, commercial purposes, and ownership of mineral rights. The address reported for land without a street address should include the rural route, town and state or township, county, and state.

For the purpose of this question, certificates of deposit, bank savings or checking accounts in a savings and loan, shares in a credit union, life insurance policies, annuities, notes, bonds, debentures and mortgages need not be disclosed.

Name of Business:

Address of Business:

Type of Business:

Interest or Position:

Name of Business:

Address of Business:

Type of Business:

Interest or Position:

Name of Business:

Address of Business:

Type of Business:

Interest or Position:

Note: All financial information will be held in the strictest of confidence and all personal documents may be returned or destroyed by request after the completion of this investigation.

List all sources of income. Include approximate annual totals:

Are you currently more than 60 days delinquent on any debt or obligation? If yes, please explain:

Have you ever filed bankruptcy, had your wages garnished, had property repossessed, or been evicted from any property? If yes, please explain:

Have you ever had any property forfeited by court action? If yes, please explain:

Do you currently owe any back income, property, or other taxes? If yes, please explain:

Do you currently have any outstanding judgments or liens against you or your spouse for any property you own or have an interest in? If yes, please explain:

Are you current with the filing of required tax returns or tax documents? If no, please explain:

Do you own or control any assets or liabilities located outside the United States: If yes, please explain:

Do you control, manage or hold in trust any assets or liabilities for another person or entity? If yes, please explain:

Please attach copies of any personal tax returns and financial statements for the previous three years. Also include any personal SEC filings and a listing of personal stock holdings of more than 5% of total issued stock for any organization.

INSTRUCTIONS TO PRINTERS

FORM 4506, PAGE 1 of 2 MARGINS: TOP 13 mm (1⁄2"), CENTER SIDES. PRINTS: HEAD to HEAD

PAPER: WHITE WRITING, SUB. 20. INK: BLACK

FLAT SIZE: 216 mm (81⁄2") � 279 mm (11")

PERFORATE: NONE

4506-TForm Request for Transcript of Tax Return

OMB No. 1545-1872(January 2004) � Do not sign this form unless all applicable parts have been completed.

Department of the Treasury Internal Revenue Service

� Request may be rejected if the form is incomplete, illegible, or any required

First social security number on tax return or employer identification number (see instructions)

1a 1bName shown on tax return. If a joint return, enter the name shown first.

If a joint return, enter spouse’s name shown on tax return2a Second social security number if joint tax return2b

Current name, address (including apt., room, or suite no.), city, state, and ZIP code3

Form 4506-T (1-2004)Cat. No. 37667NFor Privacy Act and Paperwork Reduction Act Notice, see page 2.

I.R.S. SPECIFICATIONS TO BE REMOVED BEFORE PRINTING

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

TLS, have you transmitted all R text files for this cycle update?

Date

Action

Revised proofs requested

Date Signature

O.K. to print

Address, (including apt., room, or suite no.), city, state, and ZIP code shown on the last return filed if different from line 34

CAUTION: Lines 6 and 7 must be completed if the third party requires you to complete Form 4506-T. Do not sign Form 4506-T if the third party requests that you sign Form 4506-T and lines 6 and 7 are blank.

If the transcript or tax information is to be mailed to a third party (such as a mortgage company), enter the third party’s name, address, and telephone number. The IRS has no control over what the third party does with the tax information.

7 Year or period requested. Enter the ending date of the year or period, using the mm/dd/yyyy format. If you are requesting more than four years or periods, you must attach another Form 4506-T.

Telephone number of taxpayer on line 1a or 2a

Sign Here

DateSignature (see instructions)

Title (if line 1a above is a corporation, partnership, estate, or trust)

Signature of taxpayer(s). I declare that I am either the taxpayer whose name is shown on line 1a or 2a, or a person authorized to obtain the tax information requested. If the request applies to a joint return, either husband or wife must sign. If signed by a corporate officer, partner, guardian, tax matters partner, executor, receiver, administrator, trustee, or party other than the taxpayer, I certify that I have the authority to execute Form 4506-T on behalf of the taxpayer.

Spouse’s signature� Date

TIP: Use new Form 4506-T to order a transcript or other return information free of charge. See the product list below. You can also call 1-800-829-1040 to order a transcript. If you need a copy of your return, use Form 4506, Request for Copy of Tax Return. There is a fee to get a copy of your return.

part was blank at the time of signature.

Read the instructions on page 2.

Product requested. Most requests will be processed within 10 business days. If the product requested relates to information from a return filed more than 4 years ago, it may take up to 30 days. Enter the return number here and check the box below. � a b c d e

Return Transcript, which includes most of the line items of a tax return as filed with the IRS. Transcripts are generally available for the following returns: Form 1040 series, Form 1065, Form 1120, Form 1120A, Form 1120H, Form 1120L, and Form 1120S. Return transcripts are available for the current year and returns processed during the prior 3 processing years

Account Transcript, which contains information on the financial status of the account, such as payments made on the account, penalty assessments, and adjustments made by you or the IRS after the return was filed. Return information is limited to items such as tax liability and estimated tax payments. Account transcripts are available for most returns

Record of Account, which is a combination of line item information and later adjustments to the account. Available for current year and 3 prior tax years

Verification of Nonfiling, which is proof from the IRS that you did not file a return for the year

Form W-2, Form 1099 series, Form 1098 series, or Form 5498 series transcript. The IRS can provide a transcript that includes data from these information returns. State or local information is not included with the Form W-2 information. The IRS may be able to provide this transcrpit information for up to 10 years. Information for the current year is generally not available until the year after it is filed with the IRS. For example, W-2 information for 2003, filed in 2004, will not be available from the IRS until 2005. If you need W-2 information for retirement purposes, you should contact the Social Security Administration at 1-800-772-1213

CAUTION: If you need a copy of Form W-2 or Form 1099, you should first contact the payer. To get a copy of the Form W-2 or Form 1099 filed with your return, you must use Form 4506 and request a copy of your return, which includes all attachments.

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INSTRUCTIONS TO PRINTERS

FORM 4506, PAGE 2 of 2 MARGINS: TOP 13 mm (1⁄2"), CENTER SIDES. PRINTS: HEAD to HEAD

PAPER: WHITE WRITING, SUB. 20. INK: BLACK

FLAT SIZE: 216 mm (81⁄2") � 279 mm (11")

PERFORATE: NONE

Page 2Form 4506-T (1-2004)

Mail or fax to the Internal Revenue Service at:

If you lived in and filed an individual return:

RAIVS Team 310 Lowell St.

Stop 679 Andover, MA 01810

978-691-6859

Maine, Massachusetts, New Hampshire, New York, Vermont

RAIVS Team 4800 Buford Hwy.

Stop 91 Chamblee, GA 30341

678-530-5326

Alabama, Florida, Georgia, Mississippi, North Carolina, South Carolina, West Virginia, Rhode Island

RAIVS Team 3651 South Interregional Hwy.

Stop 6716 Austin, TX 78741

512-460-2272

Arkansas, Colorado, Kentucky, Louisiana, New Mexico, Oklahoma, Tennessee, Texas

If you have comments concerning the accuracy of these time estimates or suggestions for making Form 4506-T simpler, we would be happy to hear from you. You can write to the Tax Products Coordinating Committee, Western Area Distribution Center, Rancho Cordova, CA 95743-0001. Do not send the form to this address. Instead, see Where to file on this page.

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to establish your right to gain access to the requested tax information under the Internal Revenue Code. We need this information to properly identify the tax information and respond to your request.

Sections 6103 and 6109 require you to provide this information, including your SSN or EIN. If you do not provide this information, we may not be able to process your request. Providing false or fraudulent information may subject you to penalties.

The time needed to complete and file Form 4506-T will vary depending on individual circumstances. The estimated average time is: Learning about the law or the form, 10 min.; Preparing the form, 11 min.; and Copying, assembling, and sending the form to the IRS, 20 min.

I.R.S. SPECIFICATIONS TO BE REMOVED BEFORE PRINTING

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Printed on recycled paper

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by section 6103.

A Change To Note

● New Form 4506-T, Request for Transcript of Tax Return, is used to request tax return transcripts, tax account transcripts, W-2 information, 1099 information, verification of non-filing, and a record of account. Form 4506, Request for Copy of Tax Return, is now used only to request copies of tax returns.

Instructions Purpose of form. Use Form 4506-T to request tax return information. You can also designate a third party to receive the information. See line 5.

Signature and date. Form 4506-T must be signed and dated by the taxpayer listed on line 1a or 2a. If you completed line 5 requesting the information be sent to a third party, the IRS must receive Form 4506-T within 60 days of the date signed by the taxpayer or it will be rejected.

Individuals. Transcripts of jointly filed tax returns may be furnished to either spouse. Only one signature is required.

Sign Form 4506-T exactly as your name appeared on the original return. If you changed your name, also sign your current name.

Corporations. Generally, Form 4506-T can be signed by: (1) an officer having legal authority to bind the corporation, (2) any person designated by the board of directors or other governing body, or (3) any officer or employee on written request by any principal officer and attested to by the secretary or other officer.

Partnerships. Generally, Form 4506-T can be signed by any person who was a member of the partnership during any part of the tax period requested on line 7.

All others. See section 6103(e) if the taxpayer has died, is insolvent, is a dissolved corporation, or if a trustee, guardian, executor, receiver, or administrator is acting for the taxpayer.

Where to file. Mail or fax Form 4506-T to the address below for the state you lived in when that return was filed. There are two address charts: one for individual transcripts (Form 1040 series) and one for all other transcripts.

Note: If you are requesting more than one transcript or other product and the chart below shows two different service centers, mail your request to the service center based on the address of your most recent return.

Chart for individual transcripts (Form 1040 series)

RAIVS Team Stop 38101 Fresno, CA 93888

559-253-4992

Alaska, Arizona, California, Hawaii, Idaho, Montana, Nevada, Oregon, Utah, Washington, Wyoming

RAIVS Team Stop B41-6700 Kansas City, MO 64999

816-823-7667

Delaware, Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, South Dakota, Wisconsin

RAIVS Team

DP SE 135

Philadelphia, PA 19255-0695

215-516-2931

Connecticut, District of Columbia, Maryland, New Jersey, Pennsylvania, a foreign country, or A.P.O. or F.P.O.

address

Mail to the Internal Revenue Service at:

If you lived in:

RAIVS Team Mail Stop 6734 Ogden, UT 84201

801-620-6922

Alabama, Alaska, Arizona, Arkansas, California, Colorado, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Louisiana, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Mexico, North Dakota, Oklahoma, Oregon, South Dakota, Tennessee, Texas, Utah, Washington, Wyoming

Connecticut, Delaware, District of Columbia, Illinois, Indiana, Kentucky, Maine, Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, South Carolina, Vermont, Virginia, West Virginia, Wisconsin

RAIVS Team P.O. Box 145500 Stop 2800F Cincinnati, OH 45250

859-669-3592

Chart for all other transcripts Documentation. For entities other than individuals, you must attach the authorization document. For example, this could be the letter from the principal officer authorizing an employee of the corporation or the Letters Testamentary authorizing an individual to act for an estate.

RAIVS Team 5333 Getwell Rd.

Stop 2826 Memphis, TN 38118

901-546-4175

Ohio, Virginia

Line 1b. Enter your employer identification number if your request relates to a business return. Otherwise, enter the first social security number (SSN) shown on the return. For example, if you are requesting Form 1040 that includes Schedule C (Form 1040), enter your SSN.

Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation, and cities, states, and the District of Columbia for use in administering their tax laws. We may also disclose this information to Federal and state agencies to enforce Federal nontax criminal laws and to combat terrorism.

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KANSAS LOTTERY SECURITY DIVISION

Date

Under penalty of perjury, I certify the answers and information provided on this background information form are true, complete and correct to the best of my knowledge.

Signature

Subscribed and sworn to before me this ______ day of _______________________, 20____.

Notary

My commission expires

Rev 2015 flyntzcj Text Box Authorized Signature for Company flyntzcj Text Box Company Title flyntzcj Line

Authorization To Obtain Consumer Credit Report

I authorize the disclosure of any information or records concerning my credit for employment or contract purposes with the Kansas Lottery, to any member of the Kansas Lottery Security Division or its designee.

Signature

Subscribed and sworn to before me this ______day of _____________________, 20____.

Notary Public Signature

My commission expires

RELEASE OF ALL CLAIMS

The undersigned has provided, will be providing, or has authorized other parties to provide to the Kansas Lottery or its designee information and documents in furtherance of a background and security investigation performed pursuant to the Kansas Lottery Act regarding the business entity or individual named below. In consideration thereof, on behalf of the named business entity and its successors and assigns, or on behalf of the named individual and his or her heirs, executors, and assigns, the undersigned hereby does release, remise, and forever discharge the State of Kansas, the Kansas Lottery, any designee of the Kansas Lottery, the Kansas Lottery Commission, and their respective members, agents, and employees, from any and all manner of actions, causes of action, suits, debts, judgments, executions, claims and demands whatsoever, known or unknown, in law or equity, which said business entity ever had, now has, may have, or claim to have against any of said parties arising out of or by reason of the processing or investigation of, or other action relating to, said background and security investigation.

(Signature of authorized person)

(Printed name and title)

(Printed name of business entity if applicable)

State of County of , SUBSCRIBED and SWORN to before me this _________ day of __________________, 20___.

Notary Public

My commission expires

AUTHORIZATION AND REQUEST TO RELEASE INFORMATION

Vendor or Applicant’s Full Name:

1. The above-named Vendor or Applicant, as is applicable (for ease of reference hereinafter referred to as “Applicant”), hereby authorizes and requests all persons or entities to whom or which this request is presented having information relating to or concerning Applicant to furnish such information to a duly appointed agent of the Kansas Lottery or designee of the Kansas Lottery, whether or not such information would otherwise be protected from disclosure by any constitutional, statutory or other legal privilege.

2 Applicant hereby authorizes and requests all persons or entities to whom or which this request is presented having documents relating to or concerning Applicant to permit a duly appointed agent of the Kansas Lottery or designee of the Kansas Lottery to review and copy any such documents.

3. If the person or entity to whom this request is presented is a brokerage firm, bank, savings and loan, or other financial institution or an office of same, Applicant hereby authorizes and requests that a duly appointed agent of the Kansas Lottery or designee of the Kansas Lottery be permitted to review and obtain copies of any and all documents, records or correspondence pertaining to Applicant, including but not limited to past loan information, notes co-signed by Applicant, checking account records, savings deposit records, safe deposit box records, passbook records, and general ledger folio sheets.

4. Applicant hereby makes, constitutes, and appoints any duly appointed agent of the Kansas Lottery or designee of the Kansas Lottery Applicant’s true and lawful attorney in fact for Applicant in Applicant’s name, place, stead, and on Applicant’s behalf and for Applicant’s use and benefit:

(a) to request, review, copy, sign for, or otherwise act for investigative purposes with respect to documents and information in the possession of the person or entity to whom this request is presented as Applicant might;

(b) to name the person or entity to whom this request is presented and insert that person’s or entity’s name in the appropriate location on this request;

(c) to place the name of the Kansas Lottery agent or the Kansas Lottery’s designee presenting this request in the appropriate location on this request.

5. A reproduction of this request by photocopy shall be for all intents and purposes as valid as the original.

IN WITNESS WHEREOF, in my personal capacity as Applicant or on behalf of the above-named Vendor for which Vendor I am duly so authorized, I have executed this document at

City: State: ______________ on this day of , 20 .

By:

(Signature)

(Printed name and title if applicable)

SUBSCRIBED and SWORN to before me this _______ day of _________________, 20____.

Notary Public

My Commission expires: _____________

Kansas Law (KS 74-8719) prohibits the purchase of lottery tickets for the following:

“It is unlawful for any person to purchase a lottery ticket or share, or to share in the lottery winnings of a person, knowing that such person is:

(1) The executive director, a member of the commission or an employee of the Kansas lottery;

(2) an officer or employee of a vendor contracting with the Kansas lottery to supply gaming equipment or tickets to the Kansas lottery for use in the operation of any lottery conducted pursuant to this act;

(3) a spouse, child, stepchild, brother, stepbrother, sister, stepsister, parent or stepparent of a person described by subsection (a)(1) or (2); or

(4) a person who resides in the same household as any person described by subsection (a)(1) or (2).

(b) (1) Violation of subsection (a) is a class A nonperson misdemeanor upon conviction for a first offense.

(2) Violation of subsection (a) is a severity level 9, nonperson felony upon conviction for a second or subsequent offense.

I have read the above and understand the information contained therein.

Signature of applicant

Date: ________________

WAIVER AGREEMENT AND STATEMENT

Fingerprint-Based Record Checks for Noncriminal Justice Purposes

I hereby authorize The Kansas Lottery to submit a set of my fingerprints to the Kansas Bureau of Investigation (KBI) for the purpose of identifying me and accessing and reviewing Kansas and/or national criminal history records that may pertain to

me. Pursuant to K.S.A. 22-4701 et seq. and K.S.A. 22-5001, The Kansas Lottery may obtain my criminal history record information for noncriminal justice purposes. By signing this waiver, it is my intent to authorize release to The Kansas

Lottery any Kansas and/or national criminal history record that may pertain to me. I further understand that, if applicable, The Kansas Lottery may choose to deny me unsupervised access to children, the elderly, or individuals with disabilities until the criminal history background check is completed.

I understand that, upon my request, the The Kansas Lottery will provide me a copy of the criminal history background report, if any, received on me, and that I am entitled to challenge the accuracy and completeness of any information contained in any such report. I may be afforded a reasonable amount of time to correct or complete the criminal history record (or decline to do so) before The Kansas Lottery makes a final decision about my status as an employee, volunteer or contractor, or my eligibility for any pertinent license, certification or registration, or adoption. See 28 CFR 50.12(b).

I understand that officials receiving the results of the criminal history record check are to use those results only for authorized purposes and are prohibited from retaining or disseminating such results in violation of federal statute, regulation or executive order, or rule, procedure or standard established by the National Crime Prevention and Privacy Compact

Council. (See 5 United States Code (USC) 552a(b); 28 USC 534(b); 42 USC 14616, Article IV(c); 28 CFR 20.21(c), 20.33(d), and 906.2(d).)

I have ____ OR have not ____ been convicted of a crime.

If convicted, describe the crime(s), the date and location of the crime(s), and the name of the convicting court:

Under penalty of perjury, I hereby declare that I am the person described below, and understand that any falsification of this statement constitutes a severity level 9, nonperson felony under the provisions of Title 21 Kansas Statutes Annotated, Section 3805.

Signature Date

Printed Name Date of Birth

Residential Address City State Zip

WAIVER AGREEMENT AND STATEMENT (Cont.)

Fingerprint-Based Record Checks for Noncriminal Justice Purposes

RIGHT TO OBTAIN AND CHALLENGE ACCURACY

OF CRIMINAL HISTORY RECORDS

To obtain a copy of your Kansas criminal history record information (CHRI) to review for accuracy and completeness, you must send a set of your fingerprints, a letter requesting your record and payment of the appropriate fee to the KBI. For further details, including the current fee, visit the following Internet website: http://www.kansas.gov/kbi/criminalhistory.

Or, to provide official court documents to make a correction you may write to:

Kansas Bureau of Investigation Attn: Criminal History Records 1631 SW Topeka Blvd Topeka, Kansas 66612-1837

If a change is made to your Kansas criminal history record due to a challenge, a new copy of your Kansas criminal history record will be sent to the Authorized Recipient to make a final decision about your status as an employee, volunteer or contractor, or your eligibility for any pertinent license, certification or registration, or adoption.

To obtain a copy of your federal CHRI for review and challenge you must submit a set of your fingerprints and the appropriate fee to the FBI. Information regarding this process may be obtained at: http://www.fbi.gov/about-us/cjis/background-checks/background_checks. Or, you may write to:

FBI CJIS Division – Record Request

1000 Custer Hollow Road Clarksburg, West Virginia 26306

The FBI will forward your challenge to the appropriate contributing agency to verify or correct the entry. Upon receipt of an official communication directly from that agency, the FBI will make any necessary changes/corrections to your record in accordance with the information supplied by that agency (see 28 CFR 16.30 through 16.34). The Authorized Recipient must submit a new set of fingerprints and fee to receive the updated federal criminal history record.

ORIGINAL – MUST BE RETAINED BY AUTHORIZED RECIPIENT

COPY – PROVIDED TO SUBJECT OF CRIMINAL HISTORY RECORD CHECK if requested

Rev 2015 http://www.kansas.gov/kbi/criminalhistory http://www.fbi.gov/about-us/cjis/background-checks/background_checks http://www.fbi.gov/about-us/cjis/background-checks/background_checks

This Consumer Credit information is for your files.

128 N Kansas Avenue Topeka, KS 66603