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Cedar City Police Department Records Request Form (Police Records Only)

Leave This Blank:

Requester Information:

First & Last Name*

Address

Daytime Phone Number:*

Email Address:*

Date (ex. 01/01/2020) :*

Signature (Please type name):*

Status:

	Not applicable because the record is public
	I am the subject of the record.
	I am the parent or legal guardian of a minor who is the subject of the record.

	I am the provider of the information.
	I have a power of attorney or notarized release from the subject of the record or provider of the information.
	I have a legislative subpoena or court order.

Description of Record(s) Requested (Must be described specifically):

Please Note: Record Request Forms are Public Documents.

FOR OFFICE USE ONLY:

Date Received: ____________________________
Time Received: ____________________________ AM or PM

CLASSIFICATION OF RECORD REQUESTED:
( ) Public
( ) Private
( ) Protected
( ) Controlled

CITY RESPONSE TO RECORD REQUEST:
( ) Released on: __________________
( ) Denied (See Attached) __________________
( ) Request for Extraordinary Circumstances (See Attached).

FEE CHARGED:__________________
SIGNATURE OF RECORD PROVIDER ____________________________________

* indicates required fields.

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