release form

SAN BENITO COUNTY SHERIFF’S DEPARTMENT POST OFFICE BOX 700, HOLLISTER, CALIFORNIA 95024-0700 PHONE: 831-636-4080 FAX: 83...

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SAN BENITO COUNTY SHERIFF’S DEPARTMENT POST OFFICE BOX 700, HOLLISTER, CALIFORNIA 95024-0700 PHONE: 831-636-4080 FAX: 831-636-1416

APPLICATION FOR RELEASE OF INFORMATION PLEASE PRINT OR TYPE: PER SECTION OF 6254 OF THE CALIFORNIA GOVERNMENT CODE, THE SHERIFF MAY BE AUTHORIZED TO RELEASE RECORDS OF COMPLAINTS OR INVESTIGATIONS CONDUCTED BY THIS OFFICE TO: Please check one: _____ Persons involved and named in report (Arrestees/Suspects excepted) _____ Persons suffering bodily injury described in report _____ Persons suffering loss or property damage listed in report _____ Authorized representatives or agents of such person (upon proof of authority) _____ Insurance carriers for such persons (attached business card) _____ Members of the public APPLICANT: ADDRESS: PHONE: AGENCY: DATE OF INCIDENT: TYPE OF INCIDENT: SPECIFIC IDENTITY OF RECORDS(S) BEING REQUESTED (REASON):

SIGNATURE:

DATE:

FOR OFFICE USE ONLY DATE PROCESSED: _____________________ APPROVED: _______ DENIED: _________ CASE NUMBER: _________________________ RECEIPT NUMBER: __________________ CLERICAL NOTES: __________________________________________________________ MISSION STATEMENT TO SERVE THE PUBLIC BY ESTABLISHING A PARTNERSHIP WITH THE COMMUNITY; TO PROTECT LIFE AND PROPERTY, PREVENT CRIME AND SOLVE PROBLEMS.