Form Builder

Required fields are marked with asterisks (*)

Disclosure Request

Once submitted a copy of this request will be received in the United Counties of Leeds and Grenville Provincial Offences office. The Defendant will also receive a copy by email.

Request Date

Name of Charged Person(s):

Last Name

First Name

You may request disclosure for up to three charge(s)/offence(s):

Charge/Offence No. 1:

Corresponding Offence/Ticket Number:

Offence Date:

Court Date (if known)

Officer and Badge Number:

Police/Detachment Name/Code (if known):

Defendant Information

Phone Number

Email Address:

Agent Information

Name

Phone Number

Email Address: