CRIMINAL RECORDS REQUEST

Requestor's Name *

First Name

Last Name

Requestor's Phone Number *

(###)

###

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Requestor's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Defendant's Name *

First Name

Last Name

Form of Payment *

Cash (In Person Only)

Check

Credit Card - I authorize the Lafayette Parish Clerk of Court to charge my Credit Card for the requested record(s).