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REQUEST FOR PUBLIC RECORDS
PER GOVERNMENT CODE 7922.535 YOUR REQUEST COULD TAKE 10 DAYS
Phone: (510) 471-1365 Fax: (510) 471-5974
Type of Report
Type of Report
Traffic Collision
Crime
Public Records Act(Type of Report)
Report
Photographs
Audio Recording
Video Recording
Report Number
Provide your name, address, and contact information.
Name
*
Date Requested
+
Address
*
Cell Number
*
Other Phone Number
*
Email Address
*
PARTY OF INTEREST (Please Check One)
Person Involved (Driver, Passenger, Pedestrian or Victim)
- Person Involved
Property Owner
- Property Owner
Authorized Individual (Signed Authorization is Required)
Authorized Individual (Signed Authorization is Required)
Parent / Guardian of Juvenile Party
Parent / Guardian of Juvenile Party
Representative of Insurance Company / Insurance Adjusting Agency
Representative of Insurance Company / Insurance Adjusting Agency
Insurance Company Name
Attorney
Attorney
Name of Firm
Other Party of Interest
Other Party of Interest
Specify Other party of interest
IF REPORT NUMBER IS NOT KNOWN, PLEASE COMPLETE:
Date / Time of Occurrence:
Location:
Name of Person on the report:
Date of Birth
+
CERTIFICATION
I declare under the penelty of perjury that I am / I represent:
(Person Named in Report)
Signed:
*
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