Records Request Form

Records Request Form
Requesters Name*

First NameLast Name
Requesters Email Address*
example@example.com
Requesters Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Requesters Phone Number*
Please enter a valid phone number.
Relation to Report (i.e. patient, homeowner, law firm)*

Requester Type*

Patient/PersonalLegalInvestigationOther Records Request

Date of Incident*

MonthDayYear
Date
Name of Involved Party*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Incident Location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Report Requested*

MedicalFireBilling
How would you like to receive the records?*

MailE-mailFax
Photo ID of Requester*

Cancelof

Date of Incident*

MonthDayYear
Date
Name of Involved Party*

First NameLast Name
Incident Location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Requesting Organization*
Type of Report Requested*

MedicalFireBilling
How would you like to receive the records?*

MailE-mailFax
Upload Records Request and Custodian Affidavit Here*

Cancelof

Date of Incident*

MonthDayYear
Date
Name of Involved Party*

First NameLast Name
Incident Location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Requesting Organization Name*
Type of Report Requested*

MedicalFireBilling
How would you like to receive the records?*

MailE-mailFax
Upload Records Request and Custodian Affidavit Here*

Cancelof

How would you like to receive the records?*

MailE-mailFax
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Requester Email Address
example@example.com
Fax Number
Please enter a valid phone number.
Type of Record*
Date Range of Records*
Detailed Description of Records Being Requested*

My Products
prevnext( X )
Patient/Personal/Public Document Records Request Fee
$ Free Quantity



Legal Records Request Fee
$15.00 Quantity



Investigation Records Request Fee
$40.00 Quantity



Total

$0.00
Other Payment Option

Records Request Fee- Mail Payment
If you prefer to pay by check, please make all checks payable to Truckee Fire Protection District. Checks can either be mailed to PO Box 2768, Truckee CA 96160, or delivered to Station 91 located at 10049 Donner Pass Rd. Truckee, CA 96161.

***Records will be released once payment is received***
Acknowledgement*

I acknowledge that all information provided is correct and authorize this request.

Payment Methods

Debit or Credit Card

First Name

Last Name

Credit Card Number

Card Expiration

Security Code

Please click one of the PayPal options to complete payment and submit the form.

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