Scribd
Upload
47 views2 pages

Pd 542 061 Verification of Incident

Uploaded by

pm69kf4rmm
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
47 views2 pages

Pd 542 061 Verification of Incident

Uploaded by

pm69kf4rmm
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

VERIFICATION OF INCIDENT

PD 542-061 (Rev. 04-22)

Requests for Verification of Incident reports from complainants/victims, their authorized representative, or an authorized third
party will be completed free of charge. Complainants/Victims designating an authorized representative must also complete
and submit a notarized AUTHORIZATION LETTER [page 2]. All applicants must enclose a stamped self-addressed envelope.
Please mail requests to: New York City Police Department, Criminal Records Section (Verification Unit), 375 Pearl Street,
Suite 4, 16th Floor, New York, NY 10038. ** E-MAIL OR MAIL-IN REQUESTS ONLY ** The Criminal Records
Section is not open to the public an do not provide in-person copies of reports. Complainants / Victims
can also request a copy of a Verification of Incident report by submitting their request online at
https://www1.nyc.gov/site/nypd/services/law-enforcement/record-requests.page. In order to find this record you
MUST furnish all information requested below, particularly the complaint number and precinct of record (occurrence).
Verification of your request cannot be made without this information. The complaint number may be obtained by calling
the precinct or detective squad concerned during the hours of 7 a.m. to Midnight.
FOR USE BY NYPD

* Complaint Number * Precinct of Report Location of Occurrence

Mail Record To: Full name and address of complainant /victim as reported to Police Department
(Print or Type)

Date reported to Police Time (if known) This report concerns:  Crime  Lost Property
 Other (describe)
Date and Time of Incident Date Time Name of officer who received your report, if known.
(if different than date of report)

Any additional information which may aid in searching for your record

Applicant’s Name Applicant’s Signature Date

FOR POLICE DEPARTMENT USE ONLY – DO NOT WRITE BELOW THIS LINE
THE FOLLOWING IS A VERIFICATION OF THE ABOVE REQUEST INCLUDING PROPERTY INVOLVED

Raised seal required for


validation
Alarm No. Report verified by (print title, name /sign) Date

PAGE 1
LETTER OF AUTHORIZATION FOR VERIFICATION OF INCIDENT REQUEST
(Only complete if designating an authorized representative)

Complainant /Victim’s Name: ________________________________________________

Address: ________________________________________________________________

________________________________________________________________

________________________________________________________________

Date of Occurrence: ___________________________

Precinct of Occurrence: ________________________

Location Incident Occurred: ________________________________________________________________

Name of Authorized Representative: ________________________________________________________

Authorized Representative’s Address: ________________________________________________________

________________________________________________________

________________________________________________________

To: New York City Police Department, Criminal Records Section (Verification Unit)
375 Pearl Street, Suite 4, 16th Floor, New York, NY 10038

This letter confirms my designation of the individual or firm listed above as my authorized representative to act on my
behalf for the sole purpose of requesting incident information from the New York City Police Department in connection
with the above-captioned occurrence and the accompanying completed VERIFICATION OF INCIDENT (PD 542-061)
form. My authorized representative is hereby granted the right of access to information and the right to act as my agent
regarding this request, and all communications sent by the New York City Police Department in regards to this request
should be directed to the attention of the authorized representative. However, this does not preclude my intervention at
a future date, and this authorization may be revoked, in writing, by me at any time.

I understand that when releasing information to the authorized representative, the New York City Police Department
has no authority to control the future use or dissemination of this information. Therefore, I release the New York City
Police Department, the City of New York and any officers, agents, or employees, thereof, from any and all liability that
may arise out of the authorized representative’s possession and the use of the information and records.

This written authorization is effective the date signed and will remain in effect until the request has been completed or
the authorization is revoked by me, in writing, whichever occurs first.

__________________________________ __________________
Complainant /Victim’s Name (Please Print)_ Date

__________________________________
Complainant /Victim’s Signature

STATE OF NEW YORK


SS.:
COUNTY OF_______________________

On the ________ day of ____________________ in the year 20 _____ before me, the undersigned, personally

appeared ____________________________________________________________, personally known to me


or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within
instrument and acknowledged to me that he /she executed the same in his /her capacity, and that by his /her signature
on the instrument, the individual, or the person upon behalf of which the individual(s) acted, executed the instrument.

___________________________________________ [Affix Notary Stamp]


Notary Signature

PAGE 2

You might also like