REQUESTER INFORMATION 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 REQUEST INFORMATION 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:
