PROVIDE THE FOLLOWING INFORMATION (All Fields Mandatory)

Agency / Organization Name:

Address:

Contact Information

First Name:

Last Name:

MI:

Contact Phone:

Fax Number:

Email:

Explain Involvement in the Case:

REQUESTED RECORD INFORMATION

You must be able to identify the record you are requesting with reasonable specificity in order to obtain a copy.

Do you know the police case number? Yes No