Law Enforcement Data Access Waiver Form

Law Enforcement Data Access Waiver Form
Please complete this form to authorize the access or release of specific law-enforcement-related data records. Do not provide sensitive government ID numbers or financial information.
Full Name of Person Granting Permission
First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Purpose of Data Access or Release
Description of Data Records to be Accessed or Released
Name of Requesting Agency or Individual
Date of Authorization
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: