SANTA MONICA POLICE DEPARTMENT
APPLICATION FOR RELEASE OF LAW ENFORCEMENT RECORDS
PART 1 - Public/Victim Request for Crime Report Information (6254(F) G.C.)
TYPE OF REPORT / RECORD:
Traffic Collision Crime Other
REPORT NUMBER (IF KNOWN):DATE AND TIME OF OCCURRENCE
LOCATION OF INCIDENT: NAME(S) OF DRIVERS/VICTIMS/PARTIES INVOLVED
NAME OF APPLICANT/COMPANY REQUESTING REPORT: MAILING ADDRESS/PLEASE PRINT CLEARLY (STREET, APT #, CITY, STATE, ZIP CODE)
HOME PHONE NUMBER: WORK PHONE NUMBER:
PARTY OF INTEREST (PLEASE CHECK ONE):
INVOLVED DRIVER/PASSENGER/PEDESTRIAN/VICTIM
DAMAGED PROPERTY OWNER
PARENT/GUARDIAN OF JUVENILE PARTY
INSURANCE COMPANY OR CLAIMS ADJUSTER ***
ATTORNEY OF RECORD ***
OTHER AUTHORIZED REPRESENTATIVE ***
LAW ENFORCEMENT AGENCY
OTHER PARTY WITH LEGAL CLAIM/LIABILITY ***
CERTIFICATION: I DECLARE UNDER PENALTY OF PERJURY THAT I AM THE PARTY OF INTEREST IDENTIFIED ABOVE:
SIGNATURE: DATE:
PRINT NAME:
IMPORTANT NOTE: EACH PAGE OF A REPORT COSTS $1.00. THE PROCESSING PERIOD FOR MAILING OUT YOUR REQUEST CAN TAKE UP TO
10 BUSINESS DAYS FROM THE DATE YOU MADE THE REQUEST (WEEKENDS AND HOLIDAYS ARE NOT INCLUDED IN THE PROCESSING TIME).
ALL REQUEST ARE MAILED BACK TO THE PERSON REQUESTING THE REPORT. CFS/DATABASE SEARCHES COST A MINIMUM OF $141.81.
PLEASE INCLUDE A REQUIRED FEE OF $2.00 IF YOU ARE REQUESTING A CRIME REPORT, OR A FEE OF $3.00 IF YOU ARE REQUESTING A
TRAFFIC ACCIDENT REPORT. ADDITIONAL FEES MAY APPLY.
PART 2 - Criminal Justice Agency Request for Local Criminal History (13300 P. C.)
CERTIFICATION: I DECLARE UNDER PENALTY OF PERJURY THAT I AM A DULY AUTHORIZED REPRESENTATIVE OF THE CRIMINAL JUSTICE
AGENCY INDICATED ABOVE, AND THAT THE REQUESTED RECORDS ARE NEEDED FOR OFFICIAL LAW ENFORCEMENT PURPOSES.
SIGNATURE:
DATE:
PRINT NAME:
SUBJECT'S NAME/DOB: REQUESTING AGENCY NAME AND CASE NUMBER
REASON:
CRIMINAL INVESTIGATION BACKGROUND OTHER (SPECIFY)
FOR OFFICE USE ONLY
CHECK #CREDIT CARD
RELEASABLE
NO: REASON :
YES: PER:
I. D. PROVIDED:
COUNTER PICK-UP: YES NO DATE:
REQUEST RECEIVED BY:
SERIAL #
Calls for Service
CALLS FOR SERVICE (CFS) ADDRESS / LOCATION DATABASE SEARCH CALLS FOR SERVICE (CFS) DATE RANGE DATABASE SEARCH
***NOTE: AUTHORIZED AGENTS MUST PROVIDE A SIGNED DECLARATION FROM THEIR CLIENT AUTHORIZING RELEASE OF DOCUMENT(S).
RECEIPT:
CASH
AMOUNT COLLECTED:
EMPLOYEE INITIAL:
DATE MAILED:
MAILED BY:
SMPD FORM #317 (Rev. 12/24/2018)
E-MAIL ADDRESS:
