CLAYTON POLICE DEPARTMENT

6000 HERITAGE TRL; CLAYTON, CA 94517

PHONE: 925-673-7350 FAX: 925-672-1429

 

REQUEST FOR COPY OF POLICE REPORT

                                   

REPORT NUMBER              ___                 TYPE OF REPORT _______________________                                                      

 

PLACE OF OCCURRENCE                                    DATE OCCURRED _____________                

 

INVOLVED PERSONS ___________________________________________________

                                                                                                                

WHAT IS YOUR INTEREST IN THE REPORT?    VICTIM          ATTORNEY ____             

 

PROPERTY OWNER         PARENT/GUARDIAN OF JUVENILE_____

 

AUTHORIZED INDIVIDUAL ___ INSURANCE COMPANY OR REPRESENTATIVE____     (Signed authorization required)

 

I declare under the penalty of perjury that I am or represent the party of interest identified in the report I am requesting a copy of.  I further state that information released will not be used to harass or humiliate any person; or used for any employment or related purposes.  I agree to indemnify the Clayton Police Department for any liability arising out of improper use of the information provided.  Dissemination of arrest information is controlled by law.

 

PRINT NAME                                                                         DATE __________________                                             

ADDRESS _______________________________________________________________                                                                                                                                      

SIGNATURE                                                                         PHONE _________________                                          

Do Not Write Below This Line

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REQUEST RECEIVED BY                                                               DATE _________________________                                  

REQUEST APPROVED BY                                                             DATE _________________________                                 

REQUEST DENIED BY                                                                    DATE _________________________

REASON DENIED ____________________________________________________________________                                                                                                                                            

HAVE REQUESTOR CALL RECORDS SUPERVISOR FOR DISCUSSION               YES                NO

 

DATE REQUEST RECEIVED                                               DATE PROVIDED ____________________                                            

 

NUMBER OF PAGES RELEASED                                        DATE MAIL

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