Name of Applicant

Agency

Home Address

Home Phone

Work Address

Work Phone

Date/Time of Incident

Location of Incident

Report Type Report Type Arrest Report Crime Report Traffic Collision DV Report Current Arrest Info/Booking Sheet Incident Report/Calls for Service Photos Other

Other

Party of Interest Party of Interest Victim named in document(s) requested Driver, passenger, or pedestrian involved in traffic collision report requested. Arrestee Witness Reporting party Insurance company representing subject of record Parent/guardian of juvenile Attorney (authorization required) Law Enforcement Officer conducting criminal investigation Property owner Authorized individual (signed authorization required) Other party of interest (specify)

Claim Number

Clients Name

Case Number

Other Party of Interest (specify)

I declare under the penalty of perjury that I am the party of interest identified above. I am NOT a suspect in this case. *If I am seeking arrest information, I declare that I am a licensed private investigator or will use the information for scholarly, journalistic, political or governmental purposes ONLY, per Government Code 6254(f)(3). The information SHALL NOT be used directly or indirectly to sell a product or service to anyone.

Signature

Date