LAKE HAVASU CITY POLICE DEPARTMENT
POLICE RECORDS REQUEST
REQUESTOR NAME:
MAILING
ADDRESS:
CITY:
STATE:
ZIP:
EMAIL ADDRESS: ADDITIONAL CONTACT INFORMATION:
REASON FOR RECORDS REQUESTED
(Check appropriate box.)
LOCATION & TYPE OF INCIDENT:
REPRESENTATIVE OF INSURANCE COMPANY/
ADJUSTING AGENCY/CLAIM # _________________
OTHER:___________________________________
* Accident Report Certification – “I certify I am an involved party, vehicle owner, or insurance company; or attorney, or private
investigator representing an involved party.”
Will the record be used in a claim against the
United States?
YES NO
**Officer worn camera (BWC) videos will be redacted in
accordance with public information laws and the entire video
will be blurred to comply with privacy acts.
Lake Havasu City, including its departments, agencies, boards, commissions, officers, officials, agents, volunteers, and employees, does not
warrant and shall not be responsible or liable for any loss, consequence, or damage resulting directly or indirectly from reliance upon the
accuracy, reliability, or timeliness of any record provided pursuant to this request. Any person or entity relying upon record provided pursuant to
this request does so at the person’s or entity’s own risk and assumes the responsibility of verifying any information used or relied upon. Lake
Havasu City is not required to create records to satisfy a request and requestors only have the right to receive records that are already in
existence and in the format in which they are currently kept.
I hereby certify under penalty of perjury that the requested records will not be used for commercial purpose as defined by A.R.S.
§ 39-121.03.
PLEASE INDICATE YOU HAVE READ THE DISCLAIMER DATE:
& CERTIFICATION ABOVE BY CHECKING THIS BOX:
Email to: courtinbox@lhcaz.gov
RECORDS AVAILABLE FOR REQUEST
(Check all that apply.)
OTHER:______________________________________
2360 McCulloch Boulevard N. | Lake Havasu City, AZ 86403-5950 | Phone (928) 855-1171 | www.LHCPD.com
DI
SCLAIMER & CERTIFICATION
RPR-PD Rev 6/19
CONTACT NUMBER:
REQUEST NO.:
DATE RECEIVED:
DATE COMPLETED:
For Internal Use Only
REPORT PICKED UP Y N
