THIS FORM MUST BE PRINTED FROM YOUR WEB BROWSER
REQUEST FOR ACCIDENT REPORT
Because some information contained in an accident report may be considered confidential, Mifflin County Regional Police will only provide a copy to owners of vehicles, drivers or passengers involved in the accident, their insurance company, or legal representative. To maintain this policy, MCRPD requires all information requested, as it pertains to you, be filled out completely. Include a check in the amount of $15.00 made payable to Mifflin County Regional Police. Note: The fee for a copy of an accident report is set by Pennsylvania State Law, 75 Pa.C.S.A. §3751. The completed form should be mailed to:
Mifflin County Regional Police
13225 Ferguson Valley Road
Yeagertown, PA 17099
Driver / Vehicle Owner Information, Required if you were the operator or owner of an involved vehicle.Last Name: ______________________ First Name: ________________ MI: _____
Address: ____________________________________________________ Apt. _____
City: __________________________________ State: ______ Zip: _____________
Driver License#: ________________________ State: ______ D.O.B.: __________
S.S. No.: ______________________ Home Telephone: ________________________
Passenger Information, Required if you were the passenger in an involved vehicle
Last Name: ______________________ First Name: ________________ MI: _____
Address: ____________________________________________________ Apt. _____
City: __________________________________ State: ______ Zip: _____________
S.S. No.: ______________________ Home Telephone: ________________________
General Information, Complete as much information as known.
Accident Date: _______________________ MCRPD Report No.: _______________
Location: ______________________________________________________________
_______________________________
Signature