open_records_request.pdf 281.69 KB Basic Information Name Email Address This is required for us to send you a confirmation that we have received your request. Records will not be sent via email. Agency Address Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Contact Phone Request Information Pursuant to the Public Information Act, Texas Government Code, Section 552, I hereby request the following information currently existing in the records of Williamson County Emergency Services District No. 4, Liberty Hill Fire Department. Type of Record You're Requesting Building Fire Vehicle Fire/Collision Medical (HIPPA Regulated) Other… Enter other… At (Location): Street Number Name of Street (Note: If at intersection, indicate both street names.) Run Number Date and Time Occurred Date and Time Occurred: Date Date and Time Occurred: Time Other Additional Information Pick Up Choice Choice of Pick-Up/Billing I wish a copy of the requested information. I understand that I will be charged $5.00 per report. Information copied onto nonstandard-size paper, cassette tapes or computer disks and photographs will require additional charges. I will pick up the copies. Choose this if you would like us to call you when the records are ready. Please bill me and mail the copies. Postage and shipping will be added to the charge of the report. I do not want copies, but wish only to inspect the requested information. Choose this option for us to give you a call to schedule a time to review the records. Phone Number Mailing Address Mailing Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code I Understand Statement I understand that the information will be released only in accordance with the Public Information Act, which may require a determination as to confidentiality by the Texas Attorney General prior to a release. I further understand that Williamson County Emergency Services District No. 4 has 10 business days in which to request such determination. Today's Date Requester's Signature This field acts as your signature and acceptance of the statement above. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. View PDF of Page
