Public Records Request Form

Name:

Address:

Email: *

Phone Number:

Date of Incident (if applicable):

Report # (if applicable):

Describe or identify the records that you want to inspect or copy:

Please see the current fee schedule above. There may be additional charges for review and/or preparation if review/preparation takes more than two hours.

I am willing to pay all fees for this request without prior notification.

I am willing to pay fees for this request up to a maximum of $__

If you estimate that the fees will exceed this limit please contact me

I am requesting that fees be waived. I am requesting this waiver on the following grounds:

If you checked the second box above please give a maximum price you will be willing to pay:

If you checked the fourth box please explain why you would like the fee waived:

Interest in Report: (check all that apply)

Directly involved in the incident/record

Legal representative for ___, who is directly involved in the record

Name or Firm:

Insurance carrier for ___

Company name:

Not directly involved in the incident/record

Other (please explain below):

If you selected other, please explain