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2. First Name*
3. Last Name*
5. Address1*
7. Address2
9. City*
10. State*
11. Zip*
13. Telephone number*
14. Email Address*
18. Select type of report/request:

    1. Accident
    2. Crime

    1. Photos
    2. Other
20. If 'Other' was selected, please specify:
22. Case or Incident Number*
24. Date/Time of Incident or Date Range
    Date/Time of Incident or Date Range Start Date

    Date/Time of Incident or Date Range Start Time

    —

    Date/Time of Incident or Date Range End Date

    Date/Time of Incident or Date Range End Time
26. Location of Incident
30. I certify that I am:*

    1. Named in the report
    2. An Authorized Representative
32. Person named in the report*
34. I declare under penalty of perjury that the above information is correct.*

    1. I understand that this report may become public record if released to me.
36. Please select delivery method:*

    1. Mail**
    2. Email**

    **Requestor must submit a valid ID to the Records Unit by fax, email, or mail. Fax: 408-379-7561 Email: recordsunit@campbellca.gov
37. Upload Valid ID*
Leave This Blank:


39. 1. Receive an email copy of this form.
40. Email address

    This field is not part of the form submission.

41. Submit Submit and Print

* indicates a required field