HTML Preview Police Accident Report Example page number 1.
POLICE REPORT REQUEST FORM
201 West Mission Street, San Jose, CA. 95110
TrafficAccident_Crime_Report_Request.doc – v20151026
Accident Reports Fees ……… Please make your check payable to “City of San Jose”
Crime Report Fees …………… (Fees will be calculated based on the number of pages in the report.)
Include a Copy of your Photo I.D. AND your Check made out to:
“Visit the link below for instructions describing how to make out your check.”
Fees Change Annually – For an updated Fee Schedule visit: http://www.sjpd.org/Records/Fees.html
If your were cited or arrested in relation to the requested crime report, contact the District Attorney’s office for the
requested documents at (408) 299-7400
Please complete all four sections below and sign: ONLY one report per request form. Please provide as much
information as possible. This form may be delivered in person or mailed to the police department.
Please include a self-addressed stamped envelope to ensure prompt delivery.
(Type out information or print out and fill in by hand.)
1. Your Name: ______________________ _______________________________________________________
First Name Last Name
Address: ___________ _____________________________ _____________________ _____ __________
Street Number Street Name City State Zip Code
Telephone: __________________________
Include Area Code
2. Check applicable type of report:
Traffic Accident Crime Report
Case Report Number ____________________________________________
Date of Incident ________________________________________________
Location of Incident: _____________________________________________
Cross Street: __________________________________________________
Other Party Involved: ____________________________________________
3. I certify that I am:
Named in the report: (Check this box to certify that you are named in the requested report.)
An Insurance Agent: _____________________________________________
(Name of Company)
A Government Agency: __________________________________________
(Name of Agency)
An Authorized Representative of: _________________________________
(Person Named in the report)
4. Please provide in complete detail your reason for requesting a copy of this report:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Signature: ____________________________________________ Date: ___________________________
Driver’s License Number: ________________________________ State: ___________________________