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2. Requestor's Contact Information
4. First Name*
5. Last Name*
7. Home Address*
9. Home Address (Line 2)
11. City*
12. State*
13. Zip*
15. Phone Number*
16. Email Address
18. Fax Number
20. Requested Information
22. Type of Record Requested*

    1. Incident Report
    2. Other
24. Date of Incident
    Date of Incident
25. Incident Number (If Known)
27. Location of Incident*
29. Location of Incident (Line 2)
31. City*
32. State*
33. Zip*
35. Names of Involved Parties (If Known)
37. Description of Incident*
39. How would you like to receive the requested information?*
    -- Select One --EmailUS MailPick-up (10 E. Main St.)

    Please be sure to provide the necessary contact information in the fields above.
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41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

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