Act 22 Request Form (Police Audio and Video Recordings) *Written request must be made within sixty (60) days of the date of the recording Date Requested: * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20222023202420252026 Request Submitted by: * - Select -Certified U.S. MailIn Person Request Submitted to: * Name of Requester: * Street Address: * City/State/County/Zip: * Telephone: * E-mail: * Records Requested (All fields are required to be completed): Incident/Event Subject to the Request: * Date: * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20222023202420252026 Time: * Hour Hour123456789101112 : Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 am pm *If the requested incident took place inside a residence, every person present at the time of the recording must be identified, unless unknown and not reasonably ascertainable. (Attach statement if more space is required). Location: * Relationship to requested event/incident: * *Display a Printer Friendly Page Leave this field blank
