EmailMe Form - CCSO REQUEST FOR PUBLIC RECORDS

Requesting Agency or Indivdual:

Name

First Last

Email

Phone

### - ### - ####

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Subject of The Request:

Name

First Last

Email

Phone

### - ### - ####

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Type of information sought (please check the appropriate box):

Criminal Offiense

Crash Report

Booking

Other (please describe below)

Other Description:

Information About The Request:

Case or Inmate Number if Known:

Date of Incident:

Time of Incident:

Location of Incident:

Records Sought (please check appropriate box):

Information identifying the person, including name, age and address;

Information concerning any charges on which the arrest or summons is based;

Information relating to the circumstances of the arrest or issuance of a summons, including: time, location, and investigating or arresting officer (other than undercover) and agency;

The reasons for the person being placed in jail;

The time and date the person was received into custody, discharged or transferred;

The amount of the person’s bail or bond, if it has been fixed;

The time and nature of the agency’s response to all complaints or requests for assistance at a defined location; and

Information about alleged crimes or infractions, including: time, date, location of the occurrence, victim information (as allowed under law), factual circumstances about the incident, and a general description of any injuries, property or weapons in

Information will be made available for inspection at the records division of the sheriff’s office, 501 E. Court Avenue, Jeffersonville, IN 47130. Records can be mailed, though government standards for copying fees may apply. If you wish to have the information mailed, please check the line below and the records division will notify you of any costs.

Mail Delivery Requested:

Yes

No

Name of Requestor:

First Last

Date Requested:

MM / DD / YYYY

Digital Signature of Requestor:

Clear

TO BE COMPLETED BY RECORDS DIVISION

A description of the section goes here.

Date Received:

MM / DD / YYYY

Clerk Name:

First Last

Date of Response:

MM / DD / YYYY

Records Available: