Government Records Request Form

"*" indicates required fields

Requester's Information

Requester's Name*

First Last

Requester's Phone*

Requester's Email*

Requester's Address*

Street Address Address Line 2 City State ZIP Code

Record Details

Name of Subject of Record*

DOB*

MM slash DD slash YYYY

Reason for Records Request

I would like to inspect (view) the records

I would like to receive a copy of the records. I understand I may be responsible for fees associated with copying charges or research charges as permitted by UCA 63G-2-203.

I authorize release of the above requested police report(s) to:

I authorize costs of up to $______ (please specify dollar amouht)

Please specify who you authorize the release of records to:

Based on UCA 63G-2-203 (4), I am requesting a waiver of copying costs because:

Releasing the record primarily benefits the public rather than the person.

My legal rights are directly affected by the record I am impoverished. (Please include information supporting your request for a waiver of the fees.)

Please explain

Supporting Information

If the requested records are not public, please explain why you believe you are entitled to access.

I am the subject of the record(s).

I am the person who provided the information.

I am authorized to have access by the subject of the record or by the person who submitted the information. (Documentation required by UCA 63G-2-202, attached below)

I am the authorized representative of the subject of the record.

Other, please explain

Documentation:

File

Max. file size: 10 MB.

Explaination:

Requester's Signature

Signature