Date: / / Requestor: Badge #: Police Department: PD INCIDENT # Office Phone: Fax: Cell Phone: Email:
Telephone Number:	Subscriber's Name:
(if known)
Location of Telephone:	Name of Telephone Company:
(if known)	(Required)
Check Applicable Boxes: ***Cannot obtain Text Message Content with an administrative subpoena***
Seeking: Subscriber Information for the time period of ____/____/20____to____/____/20____
Incoming and Outgoing Call Detail Records for the time period of ____/____/20____to____/____/20____
Incoming and Outgoing SMS Detail Records for the time period of ____/____/20____to____/____/20____
Under Chapter 271, §17B, whenever a DA has reasonable grounds to believe that records in the possession of
a telephone company are relevant and material to an ongoing criminal investigation, the DA may issue an
administrative subpoena demanding all such records in the possession of that telephone company, excluding content.
Summarize below the basis of your belief that the telephone is being used to commit a crime.
***This section must be completed. ***
**Upon completion of summary please attach police report - Please indicate if there is no police report at this time**
For use by District Attorney's Office:
Case Type/Crime Type
Approved:	ADA:	Date:
Denied:
Notes: