FD-1115 Records Modification Form

FD-1115 (12-16-2014)

OMB 1110-0000

FBI CJIS DIVISION

Records Modification Form
REQUIRED INFORMATION:

Master Name:_______________________________ DOB:_________________ Originating Agency:____________________
Additional Information: FBI #:_________________ DOA:_____________________
MODIFIED INFORMATION: (Including any warrant#, Citation #, Agency Case #, etc)
Master Name:
Name at arrest:

Sex:
HGT:

DOB:
POB:
DOA:
AKAs:

SOC:
DOO:

Race:
WGT:

SID:
Agency Case #/OCA:

EYE:

HAIR:

ORI:

SMTs:
ARREST CHARGES: FROM:
TO:
COURT CHARGES: FROM:
TO:
DISPOSITIONS: FROM:
TO:
ADDED INFORMATION: (PLEASE NOTE: if adding a date of arrest, it must be accompanied with a fingerprint card)
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
SID

Agency Case #/OCA:

DOA:_____________________
Arrest Charges:

Court Charges:

Dispositions:

(Provide State Bureau Stamp)

DOB:

SOC:

AKAs:

SMTs: