Form FD-1115 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)
Master Name:
Name at arrest:

HGT:

DOB:
POB:
DOA:
AKAs:

SOC:
DOO:

Sex:

WGT:

SID:
Agency Case #/OCA:

Race:

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 (FD-1114).
SID

Agency Case #/OCA:

DOB:

SOC:

AKAs:

SMTs:

DOA:_____________________
Arrest Charges:

Court Charges:

Dispositions:

(Provide State Bureau Stamp)

OMB 1110-0000
Rev. 12/23/2014

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. Providing your fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application.
Social Security Account Number (SSAN). Your SSAN is needed to keep records accurate because other people may have the same name and birth date. Pursuant to
the Federal Privacy Act of 1974 (5 USC 552a), the requesting agency is responsible for informing you whether disclosure is mandatory or voluntary, by what
statutory or other authority your SSAN is solicited, and what uses will be made of it. Executive Order 9397 also asks Federal agencies to use this number to help
identify individuals in agency records.
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 fingerprint 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 non-governmental 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.
Additional Information: The requesting agency and/or the agency conducting the application-investigation will provide you additional information pertinent to the
specific circumstances of this application, which may include identification of other authorities, purposes, uses, and consequences of not providing requested
information. In addition, any such agency in the Federal Executive Branch has also published notice in the Federal Register describing any systems(s) of records in
which that agency may also maintain your records, including the authorities, purposes, and routine uses for the system(s).
Paperwork Reduction Act Notice
This notice is given under the Paperwork Reduction Act of 1995. The Paperwork Reduction Act requires that the Federal Bureau of Investigation inform individuals
and other entities of the following when asking for information. The information on this form will assure identity history information is appropriately collected,
retained, amended and thus disseminated in a manner that ensures the accuracy of the record in an effort to protect individual privacy as required by 28 CFR 20.1.
It will ensure the FBI receives all of the necessary information needed to removed identity history data within the NGI, streamline the flow of information, and
ensure more timely transactions. The FD-1115 will promote timely processing by CJIS staff, minimize delays, reduce rejections to the submitting agency, and
provide for efficient updating of identity histories within the NGI systems.
The estimate average burden associated with this collection is 10 minutes per respondent, depending on individual circumstances. Comments concerning the
accuracy of this burden estimate and suggestions for reducing this burden should be directed to Department Clearance Officer, United States Department of Justice,
Justice Management Division, Policy and Planning Staff, Washington, DC 20530.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number