EMERGENCY COMMUNICATIONS DEPARTMENT
COUNTY OF HANOVER
(Virginia Freedom of Information Act)
Authorization Form for the Release of Computerized and Taped Information
REQUESTOR'S NAME: ________________________________________________________________
ADDRESS: ___________________________________________________________________________
PHONE NUMBERS: W___________________ H_____________________ FAX ___________________
INFORMATION REQUESTED: ___________________________________________________________
______________________________________________________________________________________
DATE OF REQUEST: _________________________ TIME OF REQUEST: _______________________
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MEANS OF REQUEST: (Check one) IN-PERSON ____ TELEPHONE ____ WRITTEN ____ COURT ORDER ____
DATE/TIME OF INCIDENT (S): __________________________________________________________
DEPARTMENT AFFECTED: _____________________________________________________________
TYPE OF INFORMATION: CHECK ONE: TAPE _____ CAD DOCUMENT _____ BOTH _____
INCIDENT NUMBER (S) __________________________________________________________
______________________________________________________________________________________
RECEIVED BY (
NAME/PCN) _________________PROCESSED BY (NAME/PCN) ____________________
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DEPARTMENT/AGENCY REVIEW
(
Check One): Sheriff’s Office _____ Fire / EMS _____ Animal Control _____ APD ______ Other _______
SIGNATURE ____________________________________________ DATE _________________
IF INFORMATION CANNOT BE RELEASED, STATE REASON: ______________________________
_____________________________________________________________________________________
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(Completed by Communications)
DATE RELEASED: ________________ RELEASED BY: ______________________________________
RECEIVED BY - SIGNATURE: ___________________________________________________
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CHARGE FOR INFORMATION
Total Research Hours ______ Total Number Tape (s) ______ Total Copies ______
(Research time: $20.00 Per Hour + $6.00 Per Tape or CD) (Copies: .25 per copy – after 20
th
copy)
(Hours + Tapes + Copies) = TOTAL DUE: __________ (
Checks will be made out to Hanover County)
PAID: CASH/AMOUNT: ______________ CHECK NUMBER/AMOUNT: ______________________
DATE SENT TO TREASURERS OFFICE ______________ NAME/PCN _________________________
