Records Disclosure Request Form - City Of Sumner Police Department printable pdf download

Records Disclosure Request Form - City Of Sumner Police Department

CITY OF SUMNER

POLICE DEPARTMENT

Brad Moericke, Chief

RECORDS DISCLOSURE REQUEST

DATE OF REQUEST ______________________ CASE NUMBER ______________________________

TYPE OF INCIDENT ____________________________________________________________________

TIME OF REQUEST _______________________ DATE OF INCIDENT _________________________

LOCATION OF INCIDENT _______________________________________________________________

RECEIVED BY:

FAX

FRONT COUNTER

MAIL

PHONE

NAME OF PERSON INVOLVED IN CASE ________________________________________________

YOUR NAME: _________________________________________________________________________

Print Full Name

Signature

ADDRESS ____________________________________________________________________________

PHONE NUMBER (Day) __________________________ (Evening) ______________________________

YOUR INVOLVEMENT IN CASE (i.e.: Driver, Victim, Attorney, Defendant, Etc.) __________________

_________________________________________________________________________________________________________________________________

REASON FOR REQUEST (

)

not required, but may help us to identify the records you are requesting

__________________________________________________________________________

Note: The following charges apply for the copying of Accident or Case Reports: Reports under 20 pages are free,

any additional pages are 15 cents each.

FOR OFFICIAL USE ONLY

Reviewed By: ________________________ Date: ________________ Approved [ ] Yes [ ] No

Date Disseminated: ________________________

What Was Released: _______________________________________________________________

________________________________________________________________________________

Declined: ________________________________________________________________________

Amount Charged __________________ Specialist: __________________________ Per # _______

Notes: ___________________________________________________________________________

_________________________________________________________________________________

•

1104 Maple Street, Suite 140, Sumner WA 98390-1423

253-863-6384

Fax: 253-299-5669

Records Disclosure Request Form - City Of Sumner Police Department