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2. Date of Request:*
   Date of Request:
4. **Name and Contact Information**
   You are not required to give us contact information, however, it will make it easier to contact you to arrange for an appointment to view the records and/or arrange for delivery of copied records.
6. First Name
7. Middle Initial
8. Last Name
10. Telephone #
11. Email Address:*
13. Address1
15. Address2
17. City
18. State
19. Zip
21. Records Requested
    To assist us with finding the record(s) you request, please fill out the information below.
25. Date and Time of Incident:*
    Date and Time of Incident: Start Date

    Date and Time of Incident: Start Time

    —

    Date and Time of Incident: End Date

    Date and Time of Incident: End Time
26. Identify the Records You seek*
    To allow us to expedite your request, please be as specific as possible when describing the records you are seeking. (Time, date, names of individuals involved.) If you cannot identify a specific record, you should clearly explain the type of records you are seeking, from what time-frame and what subject matter the records should contain.
28. Would you like to:*

    1. Set an appointment to review records?
    2. Request a copy of the records?
Leave This Blank:


30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit Submit and Print

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