Utah Missing Person Clearinghouse Report Form/waiver (Page 3 of 3) in pdf

AGENCY INFORMATION

LOCAL AGENCY HANDLING CASE:

LOCAL AGENCY CASE NUMBER:

STREET ADDRESS:

CITY/STATE/ZIP:

INVESTIGATING OFFICER = S NAME:

PHONE NUMBER:

OTHER INFORMATION

OTHER PERTINENT INFORMATION (Attach additional sheets, if needed, include any information regarding person’s disappearance that may assist in the

recovery of the person. If the person has been missing before, indicate where and how recovered)

INSTRUCTIONS

IMPORTANT INSTRUCTIONS

APPLICABLE ENCLOSURES

The completed Report Form should be signed by the

Current photograph of the missing person.

parent/guardian/spouse and mailed along with the applicable

enclosures to:

In cases of parental abductions, a copy of the court-

DEPARTMENT OF PUBLIC SAFETY

certified custody order stating that the reporting parent

UTAH MISSING PERSON CLEARINGHOUSE

has custody must be enclosed. (NOTE: If it is

BOX 148280

requested that the non-custodial parent=s photograph

SALT LAKE CITY, UT 84114-8280

be included in the bulletin, a copy of the court-certified

active felony warrant, which is presently in NCIC must

Toll Free Hotline: (888) 770-6477

be made available to Utah Missing Person

(801) 965-4686

Clearinghouse prior to publication of the photograph.)

The undersigned ________________________________________________ of ___________________________________

(Print name and relationship: parent, spouse, legal guardian, etc.)

(Print name of the missing person)

hereby requests that his/her name, age, description, photograph (enclosed), and circumstances surrounding his/her missing status

be published and circulated by any method subscribed to by the investigating agency or the Utah Department of Public Safety,

Missing Person Clearinghouse, which includes, but is not limited to, dissemination to the public, other law enforcement agencies,

hospitals, social services, children=s shelters, medical examiners and/or other agencies involved with missing persons.

It is further understood and agreed that any and all information supplied by me shall be truthful, and I agree to hold harmless the

Utah Department of Public Safety for any errors of omission or commission occasioned by misinformation I may supply.

I agree to hold harmless any agency or department using transmitting, or distributing this information for any errors whatsoever

occasioned by misinformation I may supply and to indemnify the Utah Department of Public Safety, all law enforcement agencies,

or other organization=s individuals, and contacts or sources of information, and undertake to hold harmless said entities from and

against all legal liabilities, including defendants= cost for suits, claims, actions or damages that the reported missing person might

prosecute against them.

I agree to notify the Utah Missing Person Clearinghouse and the investigating agency of any updated, new or additional

information concerning, the missing person and/or his whereabouts and of any changes in my address or telephone number. I

further agree that a photostatic copy of this authorization has the same effect as the original.

X_______________________________________

X___________________________________ X __________________

(Printed name of Parent/Guardian/Spouse)

(Signature of Parent/Guardian/Spouse)

(Date)

THIS BOX FOR THE USE OF THE UTAH MISSING PERSON CLEARINGHOUSE

DATE

NIC NUMBER:

WEB PAGE

VERIFIED WITH

DATE CLEARED:

MISSING PERSON PACKET

RECEIVED:

CONFIRMED:

UPDATED:

AGENCY:

FILLED OUT:

Utah Missing Person Clearinghouse Report Form/waiver Page 3

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