Hannibal Police Department

HANNIBAL POLICE DEPARTMENT

LOCAL PERSONAL ARREST RECORD REQUEST: Date of Request:______

I authorize and empower the Hannibal Police Department to research information concerning my criminal history, arrest and/or driving records and forward such information to the below listed organization or individual. I release the Hannibal Police Department and the City of Hannibal from all liability for damages that may occur from furnishing any information concerning the release of the above stated records information. A photographic copy of this authorization shall serve as the original for purposes of this authorization. By signing below, I acknowledge I have read and understand the above listed authorization, and I understand that this check will give me my arrest record within the city limits of Hannibal, Missouri only.

Signature: ______Date: ______Witness: ______

Name (print) : ______

First Middle Last Maiden

Address: ______

Street City State/Zip

Phone Number: ______Birth Date: ______Social Security Number: ______

Organization and/or individual to who records information are to be sent (after payment is received):

Name: ______

Address: ______

Phone Number: ______

REQUEST FOR A POLICE REPORT : Date of Request: ______

This is a request for records under the Missouri Sunshine Law, Chapter 610, Revised Statutes of Missouri.

I request you make available to me the police report related to:

***Please fill out as much information as possible so we can accurately find the requested record.

Description of Incident: ______Date of Occurrence:______

Names of person(s) involved in the incident: ______

______

Include any available video

Please let me know in advance of any search or copying if fees will exceed $ ______

Name of Requestor: ______SS #: ______DOB: ______

Address: ______

Street City State/Zip Phone Number

Name/Address to send record to (if different than above): ______

______

DO NOT WRITE BELOW THIS LINE. FOR OFFICE USE ONLY