Fillable NEW- Report Request ENGLISH - SPANISH (City of Gonzales)

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NEW- Report Request ENGLISH - SPANISH (City of Gonzales)

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109 Fourth Street • P.O. Box 647 • Gonzales, CA 93926 • Phone 831-675-5010 • Fax 831-675-3205
Gonzales Police Department
Select one:
☐
Report Request
☐
Background Letter
$1.00 Per Page
$32.00
NOTE: A valid government issued photo ID must accompany request.
Name:
________________________________________________
Address:
________________________________________________
Telephone:
________________________________________
__________________________________________________________
Report #:(If available)
Incident Date/Time:
Type of Incident:
☐
Involved Party in Case
☐
Insurance Carrier
☐
Involved Party in Accident
☐
Press
☐
Owner of Damaged Property
☐
Authorized Representative of Victim
☐
Other: (Explain)
Your request will be processed in accordance with the Public Records Act. Please be
advised that your request will be processed within 10 days from your request.
I certify under the penalty of perjury that the information applied for is necessary in the
interest of the due administration of the laws, and not for the purpose of assisting a private
citizen in carrying out his/her personal interest or in a manner to maliciously harass,
degrade, or humiliate any person. (Statement required by Penal Code Section 11105).
Signature
Date
FOR OFFICE USE ONLY
☐
Approved
☐
Denied
Records Supervisor
Date
KEITH WISE
CHIEF OF POLICE
SERVE • CARE • CONNECT
109 Fourth Street • P.O. Box 647 • Gonzales, CA 93926 • Phone 831-675-5010 • Fax 831-675-3205
Gonzales Police Department
Seleccione uno:
☐
Solicitud de Reporte
☐
Carta de Antecedentes
$ 1 por página
$32.00
NOTA: Una identificación con foto válida emitida por el gobierno debe acompañar a la solicitud
Nombre:
________________________________________________
Dirección:
________________________________________________
Teléfono:
________________________________________
__________________________________________________________
Informe # : ( si está
disponible)
Fecha / hora del incidente:
Tipo de incidente:
☐
Parte involucrada en el caso
☐
Aseguradora
☐
Parte involucrada en accidente
☐
Prensa
☐
Dueño de la propiedad dañada
☐
Representante autorizado de la víctima
☐
Otro: (explicar)
Su solicitud será procesada de acuerdo con la Ley de Registros Públicos.
Tenga en cuenta que su solicitud será procesada dentro de los 10 días a partir de su
solicitud. Certifico bajo pena de perjurio que la información solicitada es necesaria en interés
de la debida administración de las leyes, y no con el propósito de ayudar a un ciudadano
privado a llevar a cabo su interés personal o de manera maliciosamente hostil, de
gradar o
humillar a cualquier persona.
(Declaración requerida por la Sección 11105 del Código
Penal).
Firma
Fecha
☐
Approved
☐
Denied
Records Supervisor
Date
FOR OFFICE USE ONLY
KEITH WISE
CHIEF OF POLICE
SERVE • CARE • CONNECT
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NEW- Report Request ENGLISH - SPANISH (City of Gonzales)

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Completed 13 August 2020

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