Based upon the Federal Driver’s Privacy Protection Act, this Request must be completed before information containing personally identifiable information in the Police Report can be released without redaction. Knowledge of what access and uses are permitted under the listed Federal Act is the responsibility of the Requester.

Section I. Requester Information (*Required)

• First Name:
• *

• Middle Name:
• *

• Last Name:
• *

• Firm/Corporation:

• Phone Number:
• *

• Email:
• *

• Street Address:
• *

• Unit/Apt:

• City:
• *

• State:
• ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNETICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA HAWAII IDOHA ILLINOIS INDIANA IOWA KENTUCKY LOUSIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON OTHER PENNSYLVANIA RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS TRIBAL UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING *

• Zip:
• *

Section II. Record Information (*Required)

• Date of Incident:
• *

• Location of Incident:
• *

• Party Name to Incident:
• *

Section III. Authorization (*Required)

• (1)
• For use by any government agency, including any court Or law enforcement agency, in carrying out Is functions, Or any private person Or entity acting on behalf of a federal, state, Or local agency in carrying out its functions.

• (2)
• For use in connection with matters of a motor vehicle Or driver safety And theft; motor vehicle emissions; motor vehicle product alterations, recalls Or advisories; performance monitoring of motor vehicles, motor vehicle parts And dealers; motor vehicle market research activities, including survey research; And removal of non-owner records from the original owner records of motor vehicle manufacturers To carry out the purposes Of the Automobile Information Disclosure Act, the Anti-Car Theft Act Of 1992 And the Clean Air Act.

• (3)
• For use in the normal course of business by a legitimate business Or its agents, employees Or contractors, but only
  • a. To verify the accuracy Of the personal information submitted by the individual To the business Or its agents, employees, Or contractors; And
  • b. If such information As so submitted Is Not correct Or Is no longer correct, To obtain the correct information, but only For purposes Of preventing fraud by, pursuing legal remedies against, Or recovering On a debt Or security interest against, the individual.

• (4)
• For use in connection with any civil, criminal, administrative, Or arbitral proceedings in any federal, state, Or local court Or agency Or before any self-regulatory body, including the service of process, investigation in anticipation of litigation, And the execution of enforcement of judgments And orders, Or pursuant To an order Of a federal, state, Or local court.

• (5)
• For use in research activities And for use in producing statistical reports so long as the personal information Is Not published, re-disclosed, Or used To contact individuals.

• (6)
• For use by any insurer Or insurance support organization, Or by a self-insured entity, Or its agents, employees, Or contractors, in connection with claims investigation activities, antifraud activities, rating Or underwriting.

• (7)
• For use in providing notice To the owners Of towed Or impounded vehicles.

• (8)
• For use by any licensed private investigative agency Or licensed security service for any purpose permitted under this subsection.

• (9)
• For use by an employer Or its agent Or insurer To obtain Or verify information relating To a holder Of a commercial driver's license that is required under Chapter 313 of Title 49.

• (10)
• For use in connection with the operation of private toll transportation facilities.

• (11)
• For any other use in response To requests For individual motor vehicle records If the State has obtained the express consent Of the person To whom such personal information pertains.

• (12)
• For bulk distribution for surveys, marketing Or solicitations if the State has obtained the express consent of the person To whom such personal information pertains.

• (13)
• For use by any requester if the requester demonstrates it/he/she has obtained the written consent of the individual To whom the information pertains.

• (14)
• For any use authorized under Wisconsin law, specifically Wis. Stat. § 346.70(4)(f), which provides that any person may with proper care, during office hours, And subject To such orders Or regulations As the custodian thereof prescribes, examine Or copy such uniform traffic accident reports, including supplemental Or additional reports, statement Of witnesses, photographs And diagrams, retained by local authorities, the state traffic patrol Or any other investigating law enforcement agency. Release Of these reports Is permissible since the Wisconsin Court Of Appeals, New Richmond News v City Of Richmond, 2014 AP 1938 (Ct.App. 5/10/2016, publication recommended), has decided such use Is related To the operation Of a motor vehicle Or Public safety, And can be released without redaction.

Special Instructions

Certification (*Required)

• Certify *
• I/We certify that the information and statements on this request are true and correct, comply with the provisions of the Federal Driver’s Privacy Protection Act and understand that the willful, unauthorized disclosure of information obtained from these records for a purpose other than stated on this request, or the sale or other distribution of the information to a person or organization not disclosed in this request may result in civil and criminal penalties imposed under Title 18 U.S.C. Section 2724. I/We will also defend, indemnify, and hold harmless the City of Green Bay and its employees or agents from all claims, actions, damages, or losses arising from my/our representations made in the execution of this form, whether said representations were negligently or intentionally made to said City.