Request for Public Information

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Pursuant to the Texas Public Information Act, Chapter 552 of the Texas Government Code as amended, application is hereby made to the custodian of information for Williamson County Emergency Services District No.5, to produce for inspection or duplication or both, the following item(s):

Reports with relation to:*

Building Fire
Vehicle Fire/Collision
Medical (HIPPA Regulated)
Other

Location*

Address and street name.

Additional Street Name

If at an intersection.

Run Number

Date Occurred*

Time

: HH

MM

How do you want to recieve the requested information?*

I will pick up the copies. Please contact me when they are ready.
Mail the copies. I understand that postage will be added to the charge of the report.
I do not want copies, but would like to inspect the requested information. Please contact me when they are ready.

Phone*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

*

I agree

I understand that the information will be released only in accordance with the Public Information Act, which may require a determination as to confidentiality by the Texas Attorney General prior to a release. I further understand that Williamson County Emergency Services District No. 5 has 10 business days in which to request such determination.

*

I agree

I understand that I will be billed $30 (plus applicable postage) per request.

Request for Public Information

Request for Public Information

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