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2. Name of Requester*
3. Date Incident Occurred:
   Date Incident Occurred:

   Date Incident Occurred:
4. Or Enter Date Range
6. Address of Requester*
   Address, City, State, Zip
8. Requester Phone Number*
9. Requester Email Address and/or Fax #
13. Description of information being requested:
15. Select How You Wish to Receive Records:*

    1. Mail Report to Me
    2. Email Report to Me

    1. Fax Report to Me
    2. Call Me and I Will Pick It Up
17. *According To The Open Records Law, This Office Has 10 Business Days To Complete This Request.
19. 100 W Washington St. Stephenville, TX 76401 | Phone: 254-965-1452 Fax: 254-965-1466
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21. 1. Receive an email copy of this form.
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