LUPD Information Request Form
(Outside The University System- General Inquiry)
For each information item requested, a separate application is required. Please submit a search
and service fee of $5.00 with each application. Make check or money order payable to Liberty
University. This fee is non-refundable. Please enclose a self-addressed, stamped envelope if
you are not picking up the item in person.
Requestor (please complete the following):
Date Report Requested:
Information Being Requested:
Type of Report (if applicable):
Other Identifying Information
That Will Facilitate Records
Name / Address of the individual to whom this record is to be released to: (please print or type)
Name of Recipient:
Street Address:
City / State / Zip Code:
LUID # (if applicable)
Contact #:
Method of Payment (All payments must be made in the exact amounts of $5.00. LUPD is unable
to complete credit card transactions or transactions that require change be given to complete
Payment Type
Check / Money Order – Payment will be made via check or money order made out to the Liberty
University Police Department in the amount of $5.00.
(Records Only: Paid _____ Date__________ Initial______)
Cash – Cash payment of $5.00 will be made in the amount of $5.00 to the Front Desk staff
at LUPD.
(Records Only: Paid _____ Date_________ Initial______)
Charge to Student Account – (If Applicable) Charge in the amount of $5.00 will be
charged to the student account.
(Records Only: Paid _____ Date_________ Initial______)
Distribution Method:
Distribution Method
Postal Mail
Individual must provide a “self addressed” stamped envelope
to LUPD along with $5.00 payment prior to processing.
Individual must provide a valid e-mail address to LUPD along
with $5.00 payment prior to processing.
Individual must provide a contact # and e-mail address to
LUPD along with $5.00 payment prior to processing. LUPD
will contact the individual when the record is ready for
For Police Department Use Only:
Prepared By: ____________________________________________________________ ______________________
__________ Report Attached __________ No Report Found __________ Handled By Officer No Report Filed
Officer: _______________________________________________
____ Loss Location Not Our Jurisdiction (Suggest you try): ________________________________________________
____ Not Releasable
____ Approved For Release / ____________________________________________ ______________________
Command Staff / Administration Division Date
Report: (Circle One) Sent Picked up Emailed Date: ______ / ______ / ______ Initial: _________
Recipient Signature if picked up: _________________________________________
*Return Signed Form & Completed Package to Records Manager