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2. Please Select One or More of the Following*

   1. (A) Any person involved in the accident
   2. (B) The authorized representative of any person involved in the accident
   3. (C) A driver involved in the accident
   4. (D) An employer, parent or legal guardian of a driver involved in the accident
   5. (E) The owner of a vehicle or property damaged in the accident
   6. (F) A person who has established financial responsibility for a vehicle involved in the accident in a manner described by T.C. § 601.501, including a policy holder of a motor vehicle liability insuran
   7. (G) An insurance company that issued an insurance policy covering a vehicle involved in the accident
   8. (H) An insurance company that issued a policy covering any person involved in the accident
   9. (I) A person under contract to provide claims or underwriting information to a person described by Paragraph (F), (G), or (H);
   10. (J) A radio or television station that holds a license issued by the Federal Communications Commission
   11. (K) A newspaper that is: i: A free newspaper of general circulation or qualified under § 2051.044, Government Code, to publish legal notices; ii: Publish at least once a week; and iii: Available and o
   12. (L) Any person who may sue because of death resulting from the accident
   13. An agency of the United States, this state (Texas) or a local government of this state (Texas)
   14. I do not meet any of the qualifications listed above, however, I certify that I am a person directly concerned in the accident or have a proper interest therein.
4. Please provide an explanation for how you meet this requirement.
7. First Name
8. Last Name
10. (your first and last name) certify that I meet the requirements of Texas Transportation Code § 550.065 (c)(4) to obtain a copy of the requested crash report based on the above selected qualification(s).
12. Providing false information on this governmental record is a violation of Texas Penal Code § 37.10 and could result in criminal penalties.
14. Organization Name (If checking G, H, I, J or K above):
16. Phone Number
18. Email Address
20. If you did not indicate that you meet the qualifications of Texas Transportation Code § 550.65 (c)(4) by either checking a qualification listed above or providing sufficient justification for your qualification, then a redacted copy will be provided.
22. T.C., § 550.065(c-1) the department or the governmental entity that receives the information shall create a redacted accident report that may be requested by any person.
26. REQUEST FOR COPY OF PEACE OFFICER’S CRASH REPORT
28. Mail To: Pilot Point City Hall 102 East Main Street Pilot Point, Texas 76258
30. Make Check or Money Order To: City of Pilot Point
31. Questions: Call (940) 686-2165
33. CHECK TYPE OF SERVICE DESIRED*

    1. Copy of Peace Officer’s Crash Report-$6.00 Each
    2. Certified Copy of Peace Officer’s Crash Report-$7.00 each
35. DATE OF REQUEST:
36. CLAIM OR POLICY NO.
37. CRASH CASE ID#
39. Please provide as accurate and complete information as possible:
41. Crash Date (Month/Day/Year)
42. Crash Location (County, City, Street or HWY)
44. Was anyone killed in the crash?

    1. Yes
    2. No
45. If so, name of deceased
47. Investigating agency (if known)
48. Investigator Name (if known)
49. Officer ID#
51. Driver's Full Name
52. Date of Birth
53. Driver License #
54. Address (if available)
56. Person Involved In Crash Full Name
    (Passenger, Owner/Lessee, Pedestrian. Pedalcyclist or Property Owner
57. Address (if available)
59. Important Information
    *Texas Statute allows the investigating officer 10 days in which to submit his/her report.
61. *Requests should not be submitted until at least 10 days after the crash date to allow time for receipt for the report.
63. *The Law also provides that if an officer’s report is not on file when a request for a copy of such report is received, a certification to that effect will be provided in lieu of the copy and the will br retained for the certification.
65. Mail to
67. Address
69. City
70. State
71. Zip Code
73. Phone Number
74. Fax Number
76. Email Address
78. Requested by
80. Acknoweledgement*

    1. Yes

    I am requesting information pursuant to the Texas Public Information Act. I understand that the Pilot Point Police Department reserves the right to seek an Attorney General’s opinion regarding the disclosure of the records requested. I understand the failure to provide a detailed description of the specific information I am seeking may result in a delay in completing my request. I understand that there is a charge for the information that I am requesting. I understand that the City of Pilot Point has 10 business days to complete my request. By submitting this form you acknowledge the above statement.
82. FOR OFFICE USE ONLY
    Date Request Received: ______________________________ Received By:_______________________________________________ ____Report Sent via___________________ Date Sent:_______________________ ____Date Picked Up:_______________________ ____Report Not On File Date Completed:________________________________ Comments:___________________________________________________________________________________________________
Leave This Blank:


84. 1. Receive an email copy of this form.
85. Email address

    This field is not part of the form submission.

86. Submit

* indicates a required field