Wylie Police Department Accident Report Request Form printable pdf download

WYLIE POLICE DEPARTMENT ACCIDENT REPORT REQUEST FORM

2000 N. HWY 78

WYLIE, TEXAS 75098

972-442-8170 OFFICE / 972-442-8173 FAX

NOTICE TO REQUESTOR:

All requests must be made in writing and may be submitted in person or by mail

The fee for 1 copy of Peace Officer’s Crash Report (CR-3) is $6.00 / certified copy is $8.00. We accept cash ( exact change), check,

and debit/credit cards (an additional $3.00 processing fee will be assessed when using a debit/credit card).

REQUESTOR’S CONTACT INFORMATION (please print all information)

DATE: ______________________________

CASE NUMBER (if available): ____________________________________

REQUESTOR’S NAME: ____________________________________________________________________________________

TELEPHONE NUMBER: ___________________________

E-MAIL:_______________________________________________

Please certify how you are directly concerned in the motor vehicle accident or have a proper interest therein by checking the

applicable box below:

 Driver

 Pedestrian

 Pedalcyclist

 Passenger

 Employer of driver

 Parent / legal guardian

of driver

 Owner of vehicle or property damaged

 Policyholder / person with financial

 Insurance company of

responsibility for vehicle

vehicle or person involved

 Courier service for insurance company  Radio / television station that holds

 Newspaper (qualified under

FCC license

Section 550.065(c)(4)(K))

 Legal representative of:

 Other person concerned or having

 None of the above

proper interest in accident

My name is ________________________________________________, my date of birth is _____________, and my address is

_____________________________________________________________, USA. I declare under penalty of perjury that the

foregoing is true and correct. Executed in _____________ County, State of _____________, on the ____ day of ____________, 20__.

______________________________________

Signature

ACCIDENT INFORMATION (please print all information)

1. DRIVER’S NAME: _______________________________________

DATE OF ACCIDENT:___________________________

3. LOCATION OF ACCIDENT:_________________________________________________________________________________

The Wylie Police Department adheres to the requirements of Chapter 550 of the Texas Transportation Code

regarding the release of crash report information and any applicable fees.

OFFICE USE ONLY

Released by:____________________________ _ Information provided:_________________________________________________________

Method of payment: cash:______________ check #:_______________ debit/credit card:______________ receipt #:______________________

Wylie Police Department Accident Report Request Form

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