REQUESTER NAME: DATE: 
 
PHONE NUMBER: YOUR EMAIL ADDRESS: 

ORGANIZATION NAME (for business requests or requests made on behalf of clients): 


LEGAL ADDRESS: 


Is the requestor or the party for whom the requestor is acting on behalf of a resident of the Commonwealth of Virginia?
  Yes   No

DPSC EVENT NUMBER (if known): FCPD CASE NUMBER (if known):

INCIDENT DATE: APPROXIMATE INCIDENT TIME:

TYPE OF RECORD(S) REQUESTED:


INCIDENT ADDRESS: 


PHONE NUMBER(S) USED:

PERSON(S) INVOLVED:


DESCRIPTION OF INCIDENT:


ADDITIONAL REMARKS: