Record Request Form (Online)

2. 

3. Records Request Form
   COST: .50 cents per page(8.5 x 11) $5.00 flat rate for requests by insurance companies (not including photos) $10.00 CD Additional fees may apply.Contact Records for rates specific to your request. **Report will be destroyed if it is not picked up within 14 days of notification**

   COST: .50 cents per page(8.5 x 11) $5.00 flat rate for requests by insurance companies (not including photos) $10.00 CD Additional fees may apply.Contact Records for rates specific to your request. **Report will be destroyed if it is not picked up within 14 days of notification**

5. INSTRUCTIONS
   This form must be completed accurately.Your signature affirms that the requested information will not be used for a commercial purpose and acknowledges that such a violation is punishable by a civil penalty -A.R.S 39-121.03

   This form must be completed accurately.Your signature affirms that the requested information will not be used for a commercial purpose and acknowledges that such a violation is punishable by a civil penalty -A.R.S 39-121.03

7. Person Requesting Report Copy

8. Case Number

10. Nature of Incident (Accident,Burglary,Assault Etc...)

11. Location of Incident

13. Date and Time of Incident

15. Phone Number (to advise when report is ready)

17. Email Address

19. CHECK ONE: I am the*

    1. Victim
    2. Suspect
    3. Media Outlet
    4. Other

20. Explain Other

Leave This Blank:


22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit

* indicates a required field