MISSOURI STATE HIGHWAY PATROL
CUSTODIAN OF RECORDS
PUBLIC RECORDS REQUEST

SHP-804E 07/14



REQUESTOR'S INFORMATION (All Fields in this section that have an asterisk (*) must have a value.)

Note: ("Title" below refers to Mr., Mrs., Officer, Sgt, Lt, etc.)
























  •  (999-999-9999)






By law, certain records may be open upon request to certain individuals but closed to the general public. Please state your interest in the records requested (such as general public, party, or representative of a party, victim, etc.) so that we may determine whether those records, if closed to the public, may be available to you. Investigative reports will be disseminated in compliance with Missouri Statute 610.100.


















RECORDS INFORMATION (Please fill in as much information as possible.)





  •  (mm/dd/yyyy)


  •  (hh:mm)


  • AM  


  • PM  

NAME(S) OF PERSON(S) INVOLVED DATE OF BIRTH
(mm/dd/yyyy)
SOCIAL SECURITY
NUMBER
(last four digits)




























































  • (1000 character limit so be as specific as possible)
    (characters remaining =  )


  • In compliance with 18 U.S.C. 2721, also known as the Driver's Privacy Protection Act, and in order to receive an unredacted record (except for social security numbers), you must meet one of the following criteria. Requesting parties not meeting one of the criteria will receive a record in which personal information, as defined in 18 U.S.C. 2725 (3 & 4), has been redacted.
    Check all that apply below:


  •  1.  Government agency or representative carrying out its functions.

  •  2.  In connection with matters of motor vehicle or driver safety and theft.

  •  3.  In connection with motor vehicle: Emissions, product alterations, recalls, advisories, performance monitoring, parts and dealers, market research (including survey research ) and / or removal of non-owner records from the original owner records of motor vehicle manufacturers.

  •  4.  Legitimate business or its agents, employees, or contractors to:
    • verify the accuracy of personal information submitted by the individual to the business or its agents, employees, or contractors; and
    • to obtain the correct information (if information submitted is not correct), but only for the purposes of preventing fraud by, pursuing legal remedies against, or recovering on a debt or security interest against the individual.

  •  5.  For use in connection with any civil, criminal, administrative, or arbitral proceeding. This includes service of process, investigation in anticipation of litigation, and the execution of enforcement of judgments and orders, or pursuant to an order of a court.

  •  6.  Research activities, and for use in producing statistical reports. (Note: the personal information obtained cannot be published, redisclosed, or used to contact individuals).

  •  7.  Insurer, insurance support organization, self-insured entity (or its agents, employees, or contractors), in connection with claims investigation activities, antifraud activities, rating or underwriting.

  •  8.  Providing notice to the owners of towed or impounded vehicles.

  •  9.  Licensed private investigative agency or licensed security service (Note: Cannot be selected alone. Must include another purpose).

  •  10.  Employer or its agent or insurer to obtain or verify information relating to a holder of a commercial driver's license that is required under chapter 313 of title 49 of the United States Code.

  •  11.  Use in connection with the operation of private toll transportation facilities.

  •  12.  A party involved in the incident has provided written consent to disseminate the incident report to me (Note: Written consent must accompany this request - Personal information from parties not providing written consent will be redacted.).

  •  13.  I was a party involved in the incident. (In compliance with the Driver's Privacy Protection Act, the report you receive will have all personal information for other parties redacted).



I certify, under penalty of perjury, that the information provided on this form is true and accurate to the best of my knowledge and belief, and any misrepresentation or falsification made by me on the form may result in discontinuance of incident report copies disseminated to me or my company from the Missouri State Highway Patrol, civil penalties, criminal penalties, or a combination thereof.

I certify, under penalty of perjury, that I am obtaining the personal information contained in the report for use in one of the permitted ways set out in 18 U.S.C. 2721(b).



(typed signature will be accepted in lieu of written signature)

The Custodian of Records Section accepts electronic requests for records but does not respond to e-mail. This shall satisfy the statutory requirement of a response within three business days following the receipt of your request. Requests for records may take approximately 20-30 business days to process depending on the nature of the request and research backlog. Please do not call to check the status of your request until 30 business days after your request was submitted. If you wish to withdraw your request or need further clarification regarding your request please call.

Missouri State Highway Patrol
Custodian of Records Section
P.O. Box 1408
Jefferson City, MO 65102-9500
Phone: 573-526-6146 or 573-526-6167
Fax: 573-751-9382

  • Click submit to send this form electronically to the Missouri State Highway Patrol Custodian of Records. You will receive a confirmation email from the Custodian of Records once this form is received, if you provided an email address above. Included in the email will be a a copy of the completed form.

    Note: Once submitted the form will be cleared. Use the print option for a copy for your records or to send the request in via fax or USPS.