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2. REQUESTING PARTY INFORMATION
4. First Name
5. Last Name
7. Address1
9. Address2
11. City
12. State
13. Zip
15. Phone Number
16. Email
17. Preferred Method of Contact

    1. Phone Call
    2. Text
    3. Email
21. INCIDENT INFORMATION
23. Incident Number (if known)
24. Case Number (if known)
26. Please indicate all of report elements you wish to receive

    1. REPORT - $11 per report
    2. PHOTOGRAPHS - $11 per a CD
    3. AUDIO - $42 per 15 minutes on a CD
    4. VIDEO - $59 per 15 minutes on a CD

    Fees are based on the City of Citrus Heights Fee Schedule

28. Requestor's connection to report or connection to involved party
32. COMPLETE SECTION IF INCIDENT / CASE NUMBER(S) ARE UNKNOWN
34. Date of Incident
    Date of Incident
35. Location of Incident
37. Name of Involved Party if Different than Requestor
41. Proof of Identity

    Please include a picture of yourself holding your government-issued ID, as well as a close-up photo of your photo ID, so we can process your request. If you are an insurance company or law firm representing a client, please include your signed client authorization.

    If you decline to upload proof of identity, your ID can be verified in person when the request is completed. 

43. Upload Proof of Identity Photos
47. Requestor Signature

    1. Agree
    2. Do Not Agree

    I agree that my typed name below is the legal equivalent of my manual/handwritten signature on this document. By selecting “I agree” using any device, means, or action, I agree that my signature on this document is as valid as if I signed the document in writing.

49. First Name
50. Last Name
51. Signature Date
    Signature Date
53. Please Note

    Government Code Sections §7923.600 to §7923.625 governs releasable information and who is entitled to receive that information.

Leave This Blank:


55. 1. Receive an email copy of this form.
56. Email address

    This field is not part of the form submission.

57. Submit Submit and Print

* indicates a required field