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1. Section 1: Requestor Information This section is complete This section is incomplete
2. Section 2: Record Information This section is complete This section is incomplete
3. Section 3: Authorization This section is complete This section is incomplete
4. Section 4: Penalties This section is complete This section is incomplete
5. Section 5: Certification This section is complete This section is incomplete

Section 1: Requestor Information

Incident Number*
Date of Accident/Incident*
Date of Accident/Incident
Type of Incident*
Name of person about whom record(s) are requested*
Reason for request of particular items of "personal information" or "highly restricted personal information"*
Requester, please note: Under Wisconsin law a request for access to a public record “is deemed sufficient if it reasonably describes the requested record or the information requested.” However, “a request for a record without a reasonable limitation as to subject matter or length of time represented by the record does not constitute a sufficient request.” (See State Statute 19.35(1)(h), Wis Stats.
PURSUANT TO SEC. 19.35 (4) (B), WIS STATS, YOU ARE HEREBY NOTIFIED THAT IF YOUR REQUEST WAS MADE IN WRITING AND DENIED IN WHOLE OR IN PART, YOU HAVE A RIGHT TO REVIEW BY “WRIT OF MANDAMUS” OR UPON APPLICATION TO THE DISTRICT ATTORNEY, OR ATTORNEY GENERAL.
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The Driver Privacy Protection Act (DPPA) is enforced by the U.S. Department of Justice, which may seek civil and criminal penalties for improperly obtaining, disclosing, or using personal information from a motor vehicle record for a purpose not permitted by the DPPA. In addition, private citizens may also seek civil damages in Federal Court.
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Certification 1:*
I agree that the use of the records I have requested is specifically authorized under the laws of the State of Wisconsin and the DPPA and that my intended use of the records is related to the operation of a motor vehicle or public safety or for other use as identified above.
1. I AGREE.
Certification 2:*
I certify that the information and statements on this request are true and correct and understand that the unauthorized disclosure of information obtained from these records for a purpose other than stated on this request form, 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.
1. I AGREE.
Certification 3:*
I further understand that I have the right to request a mandamus review of the responses provided to this request under Wisconsin Statute Section 19.37(1).
1. I AGREE.
Requestor Signature
If any exceptions number 2-14 are checked, requestor is required to pick up the records in person and provide a signature at time of pickup.
Date
Date
FOR AGENCY USE ONLY:
Request Approved:
YES ___________ (initials) NO ____________ (initials)
Redactions:
YES ___________ (initials) NO ____________ (initials)
Date Completed
_____________________

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