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2. Name*
3. Email Address*
5. Address*
7. City*
8. State*
9. Zip Code*
11. Phone Number*
12. Fax Number
14. If you have the Police CFS number, please list it here.

    Please list the case number for the record you are requesting. The case number starts with a two-digit year followed by a set of numbers. Ex. 20-12345. You may list more than one. Please separate them with a comma. If you do not have a CFS number use this area to explain in as much detail as possible (i.e. Dates & Location) what information you are looking for

16. When the records are ready and payment received how would you like to receive your requested information?*

    1. Mail them to me at the above address
    2. Call me at the above number for pickup at the Public Safety Complex
    3. Email them to me at the above email address

    Please only select one option.

20. OFFICIAL USE ONLY
    * = prior authorization of Town Law Department is required
22. □ Records Section staff who received the request: Initials_____
24. □ date request was received: ______________
26. □ date of status letter to requestor: _________________
28. □ date copies were mailed or requestor was called for pickup: ______________
30. □ total Fee for the request (.50 cents per page) __________

32. □ total fee per CD/DVD $19.50 ___________

34. □ total fee per flash drive $26.00  _______

36. □ date fee was paid______________
38. □ requestor notified by letter/email dated _________________ that any record will not be provided because:
40. □ the record does not exist or could not be located after a thorough search
42. □ electronic data could not be provided in the requested format*
44. □ exempt from disclosure because:* ___________________________________________________
Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field