UC Santa Barbara Police Department
Public Safety Building #574
Santa Barbara, CA 93106
Alex Yao
Chief of Police
PH (
805) 893-3446 FAX (805) 893-8569
REQUEST FOR CLEARANCE LETTER
Government Code 6254 (f)
Date: _______________________
Name of Requestor: _________________________________________________
(PRINT LEGIBLY)
Address: _________________________________________________________
(House number, street name, city, state, zip code)
Phone #:____________________ License/ID #:__________________
DOB: ______________________
I declare, under penalty of perjury, that I am the party of interest as stated above. I further declare under
penalty of perjury that the address information obtained pursuant to this request shall not be used
directly, or indirectly, to sell a product or service to any individual or group. Any information obtained
will not be used to commit any misdemeanor or felony offense.
Requestor’s Signature: _________________________________________________
OFFICE USE ONLY
Letter Released (Date):______________
Signature of Custodian of Records: _____________________________________
Contacted Requestor:________________________
DATE INITIALS
