1201 Broad St., P.O. Box 286, Milliken, CO 80543 (970) 587-2772●Fax (970)587-8522
Request for Release of Police Report
** Please be advised that you request will be processed immediately and
if your request is approved, the requested report will be available to you
in two working days. All fees must be paid prior to the release of any report. **
Date of Request: _________________________ Number of Copies: ____________________
Name of Person Making Request: ________________________________________________________
Address: ____________________________________________________________________________
Phone Number: __________________________ Reason for Request: _________________________
____________________________________________________________________________________
Signature: _________________________________________________
I am requesting a copy of the following Police Report.
Date of Report: ____________________________ Report Number: ______________________
Location of Occurrence: _______________________________________________________________
Nature of Report: _____________________________________________________________________
Reporting Party: ___________________________ Date of Birth: ________________________
Defendant: _______________________________ Date of Birth: ________________________
Victim: __________________________________ Date of Birth: ________________________
THIS SECTION FOR OFFICE USE
Report Released: Yes No Date Released: _______________________
If report not released state reason why: ____________________________________________________
___________________________________________________________________________________
Fees Paid: Yes No Waived Fee Amount $: _________________
_________________________________________ _______________________
Supervisor’s Signature Date
10/25/11
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