Special request for information documents from ACT Policing

This form should ONLY be used to request special information documents, where ACT Policing has provided you a quote.

Step 1 - Please complete the below, then submit the form.

Applicant/client/victim contact details

Surname *

Other names *

Date of birth * dd/mm/yyyy

Street number *

Street name *

Suburb *

State *

Postcode *

Incident

Date of incident *

Time of incident * (type unknown if unknown)

Location * (street number and name, suburb, state, postcode)

Incident number

Details of attending police

Other relevant details * (reason why documents are sought and in the case of accidents also include driver & vehicle details and insurance ref/claim number)

Entity

Entity * (Individual/Organisation/Business)

Postal address for documents * (street number & name, suburb, state & postcode)

Phone number *

Email address A payment receipt will be sent here

Declaration *

I declare that I was involved in /or am a representative of a person who was involved in the incident detailed above and I declare that the information that I have supplied in this request is true, correct and complete to the best of my knowledge.

False or misleading information is an offence *

I understand that providing false or misleading information is an offence and punishable by law.

Undertaking *

I undertake to handle personal information in accordance with the Privacy Act 1988 (Cth) and the Australian Privacy Principles. This includes using this information for purposes related to the purposes for which it was sought, and only on-disclosing the information where authorised by the Privacy Act 1988 and the Australian Privacy Principles. <BR><BR>By submitting this request, I acknowledge that additional conditions may be imposed on information provided by the Australian Federal Police.

Special report request cost

Amount ($) * This is based on figures that you have been quoted by ACT Policing