POTTSTOWN POLICE DEPARTMENT

RECORDS DIVISION

ACCIDENT REPORT REQUEST FORM

Date of Accident:                                                 

Time of Accident:                                                

Location of Accident:                                                                                                    

Pottstown Police Dept. Incident Number:              -                                         

Your Name:                                                                                                                  

Your Address:

City:                                                            State:                 Zip Code                          

Your Signature:                                                        Date of Request:                             

*Mail this completed form to the Pottstown Police Department Records Division (100 East High St. Pottstown, PA  19464-9525) along with a postage paid self-addressed envelope and a check or money order in the amount of $15.00 (payable to Pottstown Police Department) for each accident report requested.  Only completed forms accompanied with an envelope and full payment as described will be processed.

DO NOT SEND CASH