FieldComment
ORI (Originating Agency Identifier):CTC number included - do not change. This is a number assigned by DOJ to identify authorized users. Each agency must have an assigned ORI prior to submitting fingerprints.
Type of Application:CTC information included - do not change. The application type determines the dissemination criteria used in preparing the response, and each authorized agency has specific application type(s) it is permitted to use. Since agencies may have more than one authorized application type, it is important this field be filled out correctly.
Job Title Or Type Of License, Certification Or Permit:CTC information included - do not change. This is a free-form field where the agency can include the specific job title, license, certificate or permit being requested. If the Application Type and Title conflict (e.g., Foster Family License applicant type, and Petition for Adoption application title) the transaction may be rejected.
Agency Address Set Contributing Agency:CTC information included - do not change. Please print or attach a pre-printed label containing the name and address label of the authorized applicant agency requesting the fingerprint check. Those agencies authorized to use generic ORIs must ensure that the agency name in this field is identical to the name used when the ORI was authorized, otherwise the transaction may be rejected.
Mail Code:CTC number included - do not change. This is a unique number assigned by the Department of Justice to those agencies which have requested responses by electronic mail or fax. If this code is not entered, the response may be printed out and mailed instead of sent electronically. An incorrect code will cause the response to be sent to the wrong agency.
Contact Name:CTC - not applicable. Enter the person’s name at the agency authorized to receive the response. THIS IS MANDATORY FOR APPLICANTS REQUIRING A CHILD ABUSE INDEX CHECK.
Contact Telephone Number:CTC - not applicable. Enter the phone number for the Contact Person. THIS IS MANDATORY FOR APPLICANTS REQUIRING A CHILD ABUSE INDEX CHECK.
Name Of Applicant and Personal Descriptors:Applicant to enter the required fields noted with an asterisk "*".
Misc No. Bil (Billing Number):CTC form - N/A. If the agency has been assigned a billing number by the Department of Justice, that number should be recorded here. If the agency does not have a billing number, the applicant should be prepared to pay all fees associated with the transaction directly to the Live Scan operator.
Home Address:Applicant to enter home address, which is mandatory on the CTC form and for applicants requiring a Child Abuse Index check and where statute requires a notification to the applicant as well as the agency.
SignatureSignature Requirement Department of Justice requires your signature on the Form 41-LS. Your signature indicates you have received and read the Privacy Notice, Privacy Act Statement, and Applicant's Privacy Rights attached to the form 41-LS.
OCA NUMBER:Applicant to enter his/her ITIN (individual taxpayer ID number), if applicable. This does not relieve you of placing your SSN in the required field listed on section 3.
LEVEL OF SERVICE:CTC information included - do not change. Please check the appropriate box(es). Please note that your agency must be authorized by statute to receive the information requested. In addition, the APPLICANT TYPE will dictate the level(s) of service permitted. In those situations where the FBI level of service is permitted, you must check the FBI box or you will not receive a response from the FBI.
ORIGINAL ATI (Applicant Transaction Identifier) NO.:FOR RE-SUBMISSIONS ONLY. If your original ATI number is not listed on your form 41-LS, then place your original ATI number found on the last line of the Live Scan Request form on your previous Live Scan form. If the applicant’s fingerprints were previously rejected and are now being re-submitted, the ATI from the ORIGINAL Live Scan Request form must be included or the agency will be charged again for the transaction.
Supplemental Employer:Not applicable

 

Form 41-LS Instructions
Updated March 03, 2022