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Public Records Request Form - Police Department

  1. Public Records Request Form
    Except as authorized under Wis. Stat. § 19.35(l)(i) and except as required by the Federal Driver's Privacy Protection Act ("DPPA"), no request under Wis. Stat. § 19.35(1)(a) and (b) to (f) may be refused because the person making the request is unwilling to be identified* or to state the purpose of the request. However, the City of Delafield Police Department provides this form in order to assist both the Department and the requester with clarification of the specific records being requested and any fees that may apply.
  2. Address, City, State, Zip
  3. Address, City, State, Zip
  4. If for some reason we are not able to get a hold of you by the above listed number, please provide us with the general line to your business or firm.
  5. Please be as specific as possible. Depending on the depth of the search and method of delivery, the Police Department may require payment prior to researching the record.
  6. Method of Delivery*
  7. Fees
    Fees will be determined by the Police Department. Photo copies of standard sized paper in black and white are $0.25 per page. Anything less than 8.5 x 11 will also be charged at a rate of $0.25 per copy. Reproduction of page size cannot exceed 11 x 17. Photos, CD Disk, DVD, audio cassette, etc. are available. If the record is held off site, additional fees may apply. Requester is also responsible for mailing and shipping.
  8. Authorization
    Please check the statements below that allow you to obtain personal information. By submitting this form, you are acknowledging all rules and regulations associated with this form.
  9. I (we) authorize under the Federal Driver Privacy Protection Act to obtain the identified records and personal information based on the following:*
  10. DPPA
    The Driver Privacy Protection Act is enforce by the U.S. Department of Justice, which may seek civil and criminal penalties for improperly obtaining, disclosing, or using personal information from a motor vehicle record for a purpose not permitted by the DPPA. In addition, private citizens may also seek damages in Federal Court.
  11. Certification
    I (we) certify that the information and statements on this request are true and correct, comply with the provisions of the Federal Driver Privacy Protection Act, and understand that the willful, unauthorized disclosure of information obtained from these records for a purpose other than state on this request, or the sale of other distribution of the information to a person or organization not disclosed in this request may result in penalties imposed under Title 18 USC Section 2724.
  12. I have read and understand the City of Delafield Notice of Public Records Policy.*
  13. By placing your name in this space, you are agreeing to all terms in this request.
  14. Leave This Blank:

  15. This field is not part of the form submission.