UXBRIDGE POLICE DEPARTMENT

275 Douglas St.

Uxbridge, MA 01569

RECORDS REQUEST

Under the provisions of Chapter 66: Section 10 Massachusetts General Law; it is requested that the following record be released:

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Date of Incident Report Number

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Location of Incident Names of Parties Involved

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Type of Incident or Related Information

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Purpose of Request (Not to be used for Commercial Purposes)

I further agree to hold the Town of Uxbridge, its agents and employees harmless from any claim, causes of action or other liability that may arise as a result of furnishing these documents to me or as a result of my use or misuse of these documents.

Please provide the following information:

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Date of Request

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Requester’s Name (Printed) Company Name (if applicable)

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Requester’s Signature

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Address City State Zip

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(Area code) Telephone Number

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(FOR USE OF UXBRIDGE POLICE DEPARTMENT EMPLOYEES)

OK to release: As edited [ ] Unedited [ ] Authorized by: ________________________________________

(Supervisor)

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