Jackson Police Department, Request For Copy Of Police Report
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1JACKSON POLICE DEPARTMENT
SCOTT MORRISON, Chief of Police • 33 -D Broadway • Jackson, CA. 95642 • 209/223-1771
REQUEST FOR COPY OF POLICE REPORT
Tab to each question; fill out, print, sign, mail or bring to JPD
1. TYPE OF REPORT
2. DATE REPORTED
3. REPORT NUMBER
Crime _____
Traffic _____
________ / ________ / ________
________ - _____________
4. PLACE OF OCCURRENCE:
5. INVOLVED PERSONS:
6. WHAT IS YOUR INTEREST IN THE REPORT?
[ ] VICTIM
[ ] PROPERTY OWNER
[ ] PARENT/GUARDIAN OF JUVENILE
[ ] AUTHORIZED INDIVIDUAL (signed authorization required)
[ ] AUTHORIZED INDIVIDUAL
[ ] ATTORNEY
[ ] INSURANCE COMPANY OR REPRESENTATIVE
[ ] OTHER
I declare under the penalty of perjury that I am or represent the party of interest identified in the report I am requesting a copy of. I
further state that information released will not be used to harass or humiliate any person; or use for any employment or related
purposes. I agree to indemnify the Jackson Police Department for any liability arising out of improper use of the information provided.
Dissemination of arrest information is controlled by law.
PRINT NAME_______________________________________________________ DATE ________________________
ADDRESS _________________________________________________________ PHONE_______________________
SIGNATURE ________________________________________________________
1. Allow 5-7 working days from time of incident before requesting report.
2. A fee of $10.00 for the first 5 pages and 25¢ for each additional page is payable at time of request.
3. Crime reports may be released to the victim or authorized agent only.
4. Traffic reports may be released to any person or owner involved in the accident or an authorized agent.
5. Only reports or portions of reports authorized for release by Departmental General Orders will be released.
6. Reports will be mailed after receipt of fee.
7. Checks and/or money orders must be made payable to the CITY OF JACKSON.
8. Allow 10 days for receipt of report.
OFFICE USE ONLY
Request received by ____________ Date _______________
Request approved by ___________ Date _______________
Request Denied [ ] Date _____________
Reason Denied ___________________________________________________________________________
Amount Paid ________________ Amount Due ______________
Fees not Applicable [ ]
Number of pages released _______________ Date mailed ________________
A9 - 05/13/2010
A9 - 06/17/10
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