Date: / /	Requestor:	Badge #:
Police Department:	PD INCIDENT #
Office Phone:	Fax:
Cell Phone:	Email:
Seeking: Subscriber Information IP Logs
Other (please explain)
For: IP Address Email Address
Screen Name Serial Number
Posting ID Other
Date & Time (or range of dates & times) and TIME ZONE:
ISP*:	Fax:	ISP Email:
ISP Case Number (provided in response to your preservation order). If a preservation case number is not assigned, attach the confirmation you received from the ISP.

*To find the contact info for an ISP: http://www.search.org/resources/isp-list/

This is a new request follow-up request	MDAO REFERENCE (for follow up requests) #: -
This IS is NOT an emergency
I AM AM NOT concerned that notice to the subscriber by the ISP will impede the investigation (if yes, explain below)
Summarize the nature of the offense and the link between the requested records and the offense and/or nature of the emergency: ATTACH ALL RELEVANT POLICE REPORTS AND SUPPORTING DOCUMENTATION!
This request relates to a case with charges pending:: NO YES Court Docket Pending Charges:
Name of Assigned ADA:	OR not yet assigned
I am also submitting a request for phone records in connection with this investigation: NO YES
(Below Area For Use by District Attorney’s Office) Approved Denied ADA: Date:
Case Type: Crime Type: