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2. Person Requesting Record
3. Date of Request
   Date of Request
4. Case Number
6. Address
8. Email Address
9. Phone Number
11. Type of Incident
12. Date & Time of Incident
    Date & Time of Incident

    Date & Time of Incident
13. Location of Incident
15. Name of Person Involved
16. Date of Birth of Person Involved
    Date of Birth of Person Involved
18. Applicant's Interest in This Incident
20. I am the:

    1. Arrestee
    2. Attorney for (please specify)
    3. Guardian for (please specify)
    4. Media Outlet (please specify)
    5. Suspect
    6. Victim
    7. Witness
    8. Other (please specify)
21. Please provide more information.
23. Source

    1. Email
    2. Fax
    3. Front Desk
24. Record Requested

    1. Body Worn Camera
    2. Dispatch Audio
    3. Local Background Request
    4. Location History Search
    5. Photo
    6. Report
    7. Video
26. Your signature below affirms that the requested information will not be used for solicitation of business for monetary or pecuniary gain and acknowledges that such a violation is a misdemeanor and is punishable by a fine and/or imprisonment and that any booking photograph requested will not be placed in a publication or posted to a website that requires the payment of a fee or other exchange for pecuniary gain in order to remove or delete the booking photograph from the publication or web site. CR.S. 24-72-305.5 Ii[ 24-72-309.
28. Signature
    Failure to sign will result in request not being fulfilled.
29. Date
    Date
31. Tech
32. Number of Pages
33. Date
    Date
34. Fees Due/Paid
36. Remarks
38. Released By
39. Date & Time
    Date & Time

    Date & Time
41. Delivery

    1. Pickup
    2. Pickup
Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit

* indicates a required field