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2. Cotati Police Department Application for Record Information
4. **Report fee $20 (due upon receipt of report). Exact Cash, Check or Credit Card**
6. Case or Event Number
8. Record Type

   1. Traffic Collision Report
   2. Crime Report
   3. Call for Service
   4. Other
9. Other - Specify
11. Location of Incident
12. Date and Time of Incident
    Date and Time of Incident

    Date and Time of Incident
14. Persons Involved: (Driver, Passenger, Victim, Property Owners, Etc.)
16. Name
17. Date of Birth
    Date of Birth
19. Certification: I declare under penalty or perjury that I am

    1. The individual named in the report requested (Driver, Passenger, Pedestrian, Victim, Owner)
    2. The property owner in the report requested
    3. The parent / guardian of juvenile party in the report requested
    4. An authorized individual in the report requested (signed authorization is required)
    5. The Attorney of the individual named in the report requested
    6. A representative of the insurance company for the insured in the report requested
    7. Other
21. Please Specify
23. Signature
24. Date
    Date
26. Applicant Information
28. Name of Requestor
30. Mailing Address
32. City
33. State
34. Zip Code
36. Phone
37. Agency Represented (if any)
39. How would you like to receive the report?

    1. By Mail (If ID Verified)
    2. Pick Up when it is ready

41. Note: Your request will be processed within ten (10) days. An incomplete request may delay the response time. If it determined that a report is unavailable for release or if further information is needed to process the request, you will be contacted. (Govt. Code sec 6253 (c))

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50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit

* indicates a required field