Send completed form via email to: pdgramamedia@slcgov.

com or Fax to: 1-801-799-3872

SALT LAKE CITY POLICE DEPARTMENT MEDIA RECORDS REQUEST

Fee Paid: Receipt # Amount: $

Date: Requestors Name & Media Source: Address: Street Daytime Telephone: Description of Record Requested:

City Fax No.: Email Address:

State

Zip

Date of Occurrence: Location of Occurrence:

SLCPD Case No.:

Name of Involved Person(s) and Date of Birth:

I would like to inspect (view) the records. I would like to receive a copy of the records. I understand that I may be responsible for fees associated with copying charges or research charges as permitted by U.C.A. 63-2-203. I authorize costs of up to $ . I am requesting a waiver of copy costs because releasing the record primarily benefits the public rather than a person. Please explain: ___________________________________________________________ ____________________________________________________________________________________ I am requesting an expedited response as permitted by U.C.A. 63-2-204(3)(a). (Please attach information that shows your status as a member of the media and a statement that the records are required for a story for broadcast or publication, or other information that demonstrates that you are entitled to an expedited response.)

PLEASE READ THE FOLLOWING BEFORE SIGNING THIS REQUEST

Your request for records will be processed in accordance with the requirements of the Government Records Access Management Act (GRAMA), 63G-2-101, Utah Code Annotated. Your request will be processed as soon as reasonably possible, but may take up to five (5) business days to be granted. The records that may be provided to you, subsequent to your request, may contain information that is classified as protected, private, or controlled, and may only be disclosed under certain circumstances, U.C.A. 63G-2-304, 63G-2-302 and 63G-2-303. If you are dissatisfied with our response to your request, you may appeal the Police Departments decision to the Mayors Records Appeals Board by filing a written notice with the City Recorder within 30 calendar days after the date of our response, pursuant to Salt Lake City Code 2.34.140. The address is Salt Lake City Recorder, is 451 South State Street, Room 415, P.O. Box 145515, Salt Lake City, Utah 84114-5515. The Response to your request may be delayed if it is not directed to the proper person. Please send your request to the Public Information Officer or the GRAMA Coordinator, pdgramamedia@slcgov.com Signature: Date: