Criminal Justice Records Inspection Request

2. Date of Request
   Date of Request

4. Waiver to Use Criminal Justice Records
   In accordance with Colorado Revised Statutes 24-72-305.5, the undersigned applicant affirms that the information provided by the Kersey Police Department <strong>will not</strong> be used for monetary gain.

   In accordance with Colorado Revised Statutes 24-72-305.5, the undersigned applicant affirms that the information provided by the Kersey Police Department will not be used for monetary gain.

6. Applicant Information

8. Applicant Name

10. Company Name

    (if applicable)

12. Address

14. City

15. State

16. Zip Code

18. Phone

20. Applicant Signature

22. Requested Information

24. Case / Incident Report Number (if known)

25. Subject / Driver Name

27. Date and Time of Incident
    Date and Time of Incident

    Date and Time of Incident

29. Description / Location of Incident

31. Research Information

    (To be completed by Researcher / Custodian of Records)
    
    

    1. Unable to locate the record as of this date (additional information required).
    2. In accordance with Colorado Revised Statutes 24-72-100, the requested information cannot be provided.
    3. The requested information is not available at this time.
    4. No report was created for the incident.
    5. The requested information was located and provided.
33. Please explain:

35. The following information was released to the requesting applicant on

    The following information was released to the requesting applicant on

37. and

    and

40. pages were released at a fee of $5 administrative costs and $0.25 per page.

    pages were released at a fee of $5 administrative costs and $0.25 per page.

42. Total Cost for Report

43. The cost for copies of reports may be waived for victim's pursuant to 24-4.1-303(10)(a)(V).

    The cost for copies of reports may be waived for victim's pursuant to 24-4.1-303(10)(a)(V).

45. Case / Incident Number

46. Investigating Officer

48. Signature of Records Custodian

Leave This Blank:


49. Submit

* indicates a required field