RECORDS REQUEST FORM Current Date: Current Time

RECORDS REQUEST FORM
Current Date:
Current Time:
Requestor Information:
Name:
Mailing Address:
City:
State:
Home Phone #:
Fax #:
Cell Phone #:
Email Address:
Record Information:
Type of Record Requested:
If other, please explain:
Signature:
Apt:
Zip Code:
Accident Report
Name on Report:
Type of Incident/Report:
Address/Location of Incident:
Arrest Report
Incident Report
Other
Date of Incident/Report:
Case Number:
List any additional information that you may have that may help with locating the requested records (if
requesting arrest report, provide DOB of arrested individual for identification purposes):
Allow redaction of dates of birth (DOB) of living persons from records?
Preferred Method of Delivery (Check One):
Pickup at VCSO
Mail
Yes
Fax
No
Email
Note: Records Requests may take up to ten (10) business days to be completed and returned. If the records requested require approval
from the Attorney General’s office prior to release from our agency, the request may take up to an additional forty-five (45) business
days to be completed. Records Requests may be subject to charges assessed for reproducing records, labor, overhead (which is
calculated as a percentage of the total labor), and materials.
For Office Use Only:
Additional Information Required:
Clarification Received:
Yes
Yes
No
No
Date Clarification Requested:
Date Clarification Received:
Requires DA Approval:
Requires AG Ruling:
Yes
Yes
No
No
Date Sent to DA’s Office:
Date Sent to AG’s Office
AG Ruling:
Release Information
Release Information w/Redactions
Completed
Last Updated: 11/05/2015
Withdrawn
Withhold Information