2. 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.
4. Name of Person Requesting*
5. Phone Number*
7. Address*
   Address, City, State, Zip
8. Mailing Address (if different)
   Address, City, State, Zip
10. If you are representing a firm, please indicate which firm.
11. Firm Phone Number
    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.
13. Information or Records Requested*
    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.
15. Method of Delivery*

    1. Pick-up at the Police Department
    2. Have the items mailed at requester expense
    3. Email
16. Email Address
18. 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.
22. 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.
24. I (we) authorize under the Federal Driver Privacy Protection Act to obtain the identified records and personal information based on the following:*

    1. Authorized for use, if the requester demonstrates that they have obtained the written consent from the person about whom the information pertains - I am requesting a copy for my own record.
    2. Authorized for use, if the requester demonstrates that they have obtained the written consent from the person about whom the information pertains - I am a parent of legal guardian of a minor child.
    3. Authorized for use, if the requester demonstrates that they have obtained the written consent from the person about whom the information pertains - Another person (attached is their written consent).
    4. For use in connection with matters of motor vehicle safety and theft; emissions, recalls, product alteration; survey research, etc.
    5. A government agency or employed by such for the purpose of the government agency to carry out its function.
    6. A federal, state, circuit, local, or tribal court, or employed by such, for the purpose of the court to carry out its functions.
    7. A Wisconsin or out-of-state law enforcement agency, or employed by such, for the purposes of the law enforcement agency to carry out its functions.
    8. An authorized representative of a legitimate business where the driving record is used for verification to prevent fraud, pursue legal action, or collect debt.
    9. Authorized for use in connection with any civil, criminal, administrative, or arbitrary proceeding in court.
    10. Authorized for use in research activities and statistical reports - as long as the personal information is not used to contact individuals.
    11. Authorized representative of an insurer for the use in a claims investigation, anti-fraud activity, rating or underwriting.
    12. Authorized for use in providing notice to the owners of a towed or impounded vehicle.
    13. Authorized representative of an investigative agency for the purposes permitted under the Federal Driver's Privacy Protection Act.
    14. Authorized as an employer for use in obtaining information relating to a CDL.
    15. Authorized representative of a private toll transportation facility for use in the operation of that facility.
26. 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.
30. 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.
32. I have read and understand the City of Delafield Notice of Public Records Policy.*

    1. Yes
33. Notice of Public Records Policy
35. Date*
    Date

    Date
36. Name*
    By placing your name in this space, you are agreeing to all terms in this request.
Leave This Blank:


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

    This field is not part of the form submission.

40. Submit

* indicates a required field