JEFFERSON COUNTY DISTRICT COURT REQUEST FOR INFORMATION The following information is necessary for us to process the data from the Judicial Information System, or from our in-house, hard copy files. The following must be completed prior to any information released. Your request is subject to approval under the provisions of the JISCR 15, the JISC DATA DISSEMINATION POLICY, and the local Data Dissemination Policy and Procedures. Upon approval, the request will be reviewed to determine if any special program is needed, and to determine the length of time needed by the Court to answer your request. If a special program needs to be written, a programmer will receive a copy of your request and may need to contact you. There will be a charge fro any programmer services. There will be a charge for copies of a court file, unless you are personally involved in the case. NAME:_______________________________________________________________________ ADDRESS:____________________________________________________________________ PHONE:_____________________________FAX:_____________________________________ INFORMATION REQUESTED (provide as much detail as possible) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ If this information concerns a named individual, please give necessary identify information NAME_____________________________DOB____________CASE#_____________________ DATE INFORMATION NEEDED__________________________________________________ I CERTIFY UNDER PENALTY OF LAW, THAT ALL THE INFORMATION SUPPLIED ABOVE IS TRUE AND COMPLETE DESCRIPTION. ______________________________________ Name _________________,20______ Date Be advised that every effort will be made to fill your request as soon as practicable, but the routine duties of the clerks, and everyday business of the court must take priority. American LegalNet, Inc. www.USCourtForms.com