Section 1 GENERAL INFORMATION DATE OF REQUEST CASE REPORT#/REFERENCE# DATE OF INCIDENT: (Please Indicate if Estimated ) TIME OF INCIDENT: (Please Indicate if Estimated ) LOCATION OF INCIDENT: (Please Indicate if Estimated ) COUNTY OF INCIDENT: Section 2 REQUESTOR’S INFORMATION NAME COMPANY NAME ADDRESS CITY STATE ZIP PRIMARY PHONE # CELL PHONE# FAX # Section 3 DELIVERY METHOD AND SHIPPING INFORMATION PREFERRED METHOD OF DELIVERY: SHIPPING INFORMATION IS THE SAME AS REQUESTOR’S INFORMATION? FAX MAIL EMAIL Yes NAME EMAIL ADDRESS FAX # ADDRESS CITY STATE ZIP Section 4 PECUNIARY GAIN AFFIRMATION PURSUANT TO C.R.S. 24-72-305.5. I UNDERSTAND THAT COLORADO LAW PROHIBITS ME FROM USING RECORDS OF OFFICIAL ACTIONS AND CRIMINAL JUSTICE RECORDS AND THE INFORMATION IN SUCH RECORDS FOR THE PURPOSE OF SOLICITING BUSINESS FOR PECUNIARY GAIN. I HEREBY AFFIRM AND/OR SWEAR THAT THE RECORDS I OBTAIN FROM THE COLORADO STATE PATROL AS A RESULT OF THIS OPEN RECORDS REQUEST SHALL NOT BE USED FOR THE DIRECT SOLICITATION OF BUSINESS FOR PECUNIARY GAIN. DATE SIGNATURE Basic Crash Report Citation/Arrest Report Complete Case File Specify Other Report Here Agency Records $5 $5 (1st 10 pages) $0.25 $5 (1st 10 pages) $5 (1st 10 pages) $0.25 per $7.50 per additional page $0.25 per additional additional page page TYPE OF Photographs - CD or In-Car - CD Dispatch CD Audio Dispatch CD - Audio 911 Call Dispatch Chronology – DVD $25 per disk + $25 per disk + $5.00 Radio Traffic (365 day (365 day retention from $1.00 per page $5.00 postage postage retention from date of date of incident) incident) Hourly Rate Hourly Rate + $25 per disk + + $25 per disk + $5.00 $5.00 postage postage Section 5 INVOLVED TROOPER(S) NAME ID # NAME ID # Section 6 INVOLVED PARTIES PARTIES: NAME Juvenile DOB NAME Juvenile DOB NAME Juvenile DOB NAME Juvenile DOB
Section 1 GENERAL INFORMATION DATE OF REQUEST CASE REPORT#/REFERENCE# DATE OF INCIDENT: (Please Indicate if Estimated ) TIME OF INCIDENT: (Please Indicate if Estimated ) LOCATION OF INCIDENT: (Please Indicate if Estimated ) COUNTY OF INCIDENT: Section 2 REQUESTOR’S INFORMATION NAME COMPANY NAME ADDRESS CITY STATE ZIP PRIMARY PHONE # CELL PHONE# FAX # Section 3 DELIVERY METHOD AND SHIPPING INFORMATION PREFERRED METHOD OF DELIVERY: FAX MAIL EMAIL SHIPPING INFORMATION IS THE SAME AS REQUESTOR’S INFORMATION? Yes NAME EMAIL ADDRESS FAX # ADDRESS CITY STATE ZIP Section 4 PECUNIARY GAIN AFFIRMATION PURSUANT TO C.R.S. 24-72-305.5. I UNDERSTAND THAT COLORADO LAW PROHIBITS ME FROM USING RECORDS OF OFFICIAL ACTIONS AND CRIMINAL JUSTICE RECORDS AND THE INFORMATION IN SUCH RECORDS FOR THE PURPOSE OF SOLICITING BUSINESS FOR PECUNIARY GAIN. I HEREBY AFFIRM AND/OR SWEAR THAT THE RECORDS I OBTAIN FROM THE COLORADO STATE PATROL AS A RESULT OF THIS OPEN RECORDS REQUEST SHALL NOT BE USED FOR THE DIRECT SOLICITATION OF BUSINESS FOR PECUNIARY GAIN. DATE SIGNATURE TYPE OF Basic Crash Report $5 Citation/Arrest Report $5 (1st 10 pages) $0.25 per additional page Complete Case File $5 (1st 10 pages) $0.25 per additional page Specify Other Report Here $5 (1st 10 pages) $0.25 per additional page Agency Records $7.50 Photographs - CD or DVD $25 per disk + $5.00 postage In-Car - CD $25 per disk + $5.00 postage Dispatch CD – Audio Radio Traffic (365 day retention from date of incident) Hourly Rate + $25 per disk + $5.00 postage Dispatch CD - Audio 911 Call (365 day retention from date of incident) Hourly Rate + $25 per disk + $5.00 postage Dispatch Chronology $1.00 per page Section 5 INVOLVED TROOPER(S) NAME ID # NAME ID # Section 6 PARTIES: INVOLVED PARTIES NAME Juvenile DOB NAME Juvenile DOB NAME Juvenile DOB NAME Juvenile DOB
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