Public Records Request Admonition/Disclaimer Form - City of Glendale, Arizona

This Arizona-specific "Public Records Request Admonition/Disclaimer Form" is a document released by the Arizona Department of Public Safety.

Download the fillable PDF by clicking the link below and use it according to the applicable legal guidelines.

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GLENDALE POLICE DEPARTMENT
Public Records Request Admonition/Disclaimer
Any request for reports, arrest records, photos, video/audio, or crime analysis statistical products
requires a written request
To better serve you, and in order to expedite your request, we ask that you please complete and submit the original of the public
records request form once you have completed it.
You may submit this form by mailing to the address below, or
bringing it in-person to the Glendale Police Department information desk during normal work hours.
Glendale Police Department / Records Division
6835 N 57th Drive
Glendale, AZ 85301-2599
(623) 930-3100
Under provisions of Arizona’s public records law (A.R.S. §39-121, et seq.), it is requested of the Glendale Police
Department to release the requested public records to me. By signing the request, I am verifying under
penalty of perjury that these public records will not be used for commercial purposes.
Commercial Purpose is defined as: “the use of a public record for the purpose of sale or resale or for the purpose of
producing a document containing all or part of the copy, printout or photograph for sale or the obtaining of names
and addresses from public records for the purpose of solicitation or the sale of names and addresses to another for the
purpose of solicitation or for any purpose in which the purchaser can reasonably anticipate the receipt of monetary
gain from the direct or indirect use of such public record.”
If your request is for Commercial Purposes, contact the Glendale City Attorney’s Office located at 5850 West
Glendale Avenue, Glendale, AZ 85301 (623-930-2930). The Commercial Purpose Public Request form is also
available on the City of Glendale website at www.glendaleaz.com. All Commercial Purpose Public Records Request
forms must be submitted to the Glendale City Attorney’s Office.
Under penalty of perjury, I hereby declare the public records requested will not be used for Commercial
Purposes.
Caution: Arizona Revised Statutes §39-121.03(C) provides: "A person who obtains a public record for a commercial purpose without indicating the commercial
purpose or who obtains a public record for a noncommercial purpose and uses or knowingly allows the use of such public record for a commercial purpose or
who obtains a public record for a commercial purpose and uses or knowingly allows the use of such public record for a different commercial purpose or who
obtains a public record from anyone other than the custodian of such records and uses it for a commercial purpose shall in addition to other penalties be liable to
the state or the political subdivision from which the public record was obtained for damages in the amount of three times the amount which would have been
charged for the public record had the commercial purpose been stated plus costs and reasonable attorney fees or shall be liable to the state or the political
subdivision for the amount of three times the actual damages if it can be shown that the public record would not have been provided had the commercial purpose
of actual use been stated at the time of obtaining the records."
Fill in the Public Records Request Form and sign it. Any requests received that are
not filled out legibly and completely will be rejected
The Glendale Police Department reserves the right to charge for services rendered in
answering your request!
GLENDALE POLICE DEPARTMENT
Public Records Request Admonition/Disclaimer
Any request for reports, arrest records, photos, video/audio, or crime analysis statistical products
requires a written request
To better serve you, and in order to expedite your request, we ask that you please complete and submit the original of the public
records request form once you have completed it.
You may submit this form by mailing to the address below, or
bringing it in-person to the Glendale Police Department information desk during normal work hours.
Glendale Police Department / Records Division
6835 N 57th Drive
Glendale, AZ 85301-2599
(623) 930-3100
Under provisions of Arizona’s public records law (A.R.S. §39-121, et seq.), it is requested of the Glendale Police
Department to release the requested public records to me. By signing the request, I am verifying under
penalty of perjury that these public records will not be used for commercial purposes.
Commercial Purpose is defined as: “the use of a public record for the purpose of sale or resale or for the purpose of
producing a document containing all or part of the copy, printout or photograph for sale or the obtaining of names
and addresses from public records for the purpose of solicitation or the sale of names and addresses to another for the
purpose of solicitation or for any purpose in which the purchaser can reasonably anticipate the receipt of monetary
gain from the direct or indirect use of such public record.”
If your request is for Commercial Purposes, contact the Glendale City Attorney’s Office located at 5850 West
Glendale Avenue, Glendale, AZ 85301 (623-930-2930). The Commercial Purpose Public Request form is also
available on the City of Glendale website at www.glendaleaz.com. All Commercial Purpose Public Records Request
forms must be submitted to the Glendale City Attorney’s Office.
Under penalty of perjury, I hereby declare the public records requested will not be used for Commercial
Purposes.
Caution: Arizona Revised Statutes §39-121.03(C) provides: "A person who obtains a public record for a commercial purpose without indicating the commercial
purpose or who obtains a public record for a noncommercial purpose and uses or knowingly allows the use of such public record for a commercial purpose or
who obtains a public record for a commercial purpose and uses or knowingly allows the use of such public record for a different commercial purpose or who
obtains a public record from anyone other than the custodian of such records and uses it for a commercial purpose shall in addition to other penalties be liable to
the state or the political subdivision from which the public record was obtained for damages in the amount of three times the amount which would have been
charged for the public record had the commercial purpose been stated plus costs and reasonable attorney fees or shall be liable to the state or the political
subdivision for the amount of three times the actual damages if it can be shown that the public record would not have been provided had the commercial purpose
of actual use been stated at the time of obtaining the records."
Fill in the Public Records Request Form and sign it. Any requests received that are
not filled out legibly and completely will be rejected
The Glendale Police Department reserves the right to charge for services rendered in
answering your request!
GLENDALE POLICE DEPARTMENT
Public Records Request Details
Date Request Made: _______/_______/_________
Write legibly and complete all boxes please
Requestor Information:
Requestor Name
Company/Organization
Organization Representing
Title
Address
City
State
Zip Code
Home Phone
Business Phone
Cell Phone
Email Address
Purpose of Request - check one
Insurance
Government Agency
Other-Describe:
__________________________________________
Public Disclosure
Student - research
Victim of Crime
Media request
Information Requested/Type of Request - check most appropriate items
Other - Describe
Traffic Accident Report
__________________________________________________________________________________________
Criminal Police Report
__________________________________________________________________________________________
Incident History
The Glendale Police Department charges for specific requests as follows:
$5.00 (first 50 pages); 10 cents for each additional page of 50
Criminal Reports:
No charge to victim of criminal report
$5.00 (first 50 pages); 10 cents for each additional page of 50
Traffic Reports:
$7.00 per year, per address searched
Incident History:
Audio/911 CD:
$20.00 per disc
Photo CD:
$20.00 per
Statistics or Maps:
disc
$25.00
Details of Requested Item (fill out as much as you can and write legibly or your request may not be able to be filled):
Report Number
Date and Time of Occurrence
Type of Incident
City
Address of Occurrence
Additional Information:
If requesting crime statistics, data, maps or other police data or information, please include details to explain data or information needed - be very specific
A review of your request will be completed and forwarded to the appropriate unit for completion or returned to you if it cannot be completed. How would you like the information
delivered once it is completed?
Under penalty of perjury, I hereby declare the public
Email (must have entered email address above)
Pick-up in-person (6835 N 57th Dr, GPD Main Station Only)
records requested will not be used for Commercial
Mailed (USPS)
purposes.
Signature
FOR CITY USE ONLY
Date Information Released: _____________________
Released by: ________________________________
Date Request Received: _____________________________
Request Taken By: _________________________________
__________________Mailed ________________ P/U
Total Paid: _______________ No Charge (Victim) ________

Download Public Records Request Admonition/Disclaimer Form - City of Glendale, Arizona

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