2. Standard Act 22 Request Form (Police Audio and Video) 

4. IMPORTANT: PLEASE NOTE

   This form cannot be submitted online. Please PRINT THIS PAGE and handwrite your answers in. Then, please submit via mail or in person to the Patton Township Police Department. Thank you. 

6. Date Requested

   *Written request must be made within sixty (60) days of the date of the recording

8. Request Submitted By

   1. Certified U.S. Mail
   2. In Person
9. Request to be Submitted to:

   Patton Township Police Department
   Open Records Officer Tyler Jolley
   100 Patton Plaza, State College, PA 16803 

11. Name of Requester
13. Street Address:
15. City/State/County/Zip
17. Telephone
18. Email Address
22. Records Requested

    *Provide as much specific detail as possible so the agency can identify the information requested

24. Date (Required)
26. Time (Required)
28. Location (Required)

    *If the requested incident took place inside a residence, every person present at the time of the recording must be identified, unless unknown and not reasonably ascertainable. 
    (Attach Statement if more space is required) 

30. Relationship to requested event/recording (Required)

    (Attach statement if more space is required) 

32. **PLEASE NOTE: RETAIN A COPY of this request for your files**

    **It is a required document if you would need to file an appeal**

36. For Agency Use Only

38. Date Received by Agency
40. Agency thirty (30) business day response due
42. Disposition:
Leave This Blank:


43. Print Only

* indicates a required field