13
Penkridge Parish Council
Request for Disclosure of CCTV Footage under the
General Data Protection Regulation 2018
NOTE:
Information requested is provided to you at the discretion of
Penkridge Parish Council in line with our statutory requirements under the General Data Protection Regulation 2018. Failure to complete all parts of this form could result in your request being rejected.
Section One: Requested Information [to be completed in all cases]
Fields marked* are mandatory Title*
First Name*
Surname* Date of Birth
House Number* Street Name*
Town*
Postcode*
Email Address (Optional)
Date and time of incident*
Location (please also specify if a camera was fixed to a Council building)
Details of incident*
I wish to obtain CCTV footage under the GDPR 2018
I understand that my request will be handled under the GDPR 2018 and I will only receive footage of myself and that any third party information such as registration numbers will not be provided and will be pixelated.
I have:
OR
I wish to obtain CCTV footage under the GDPR 2018
I require details of third parties involved in an incident such as registration numbers. I understand that my request will be handled under the GDPR 2018 and any footage if held can only be released to a Solicitor or Insurance company acting on my behalf. We make an administration charge for such requests to cover our costs e.g. providing CCTV footage, locating and copying information. The current charge for this request is £75.00. (This fee is waived for not-for-profit organisations submitting requests on behalf of their clients.)
I have the following:
Section Two: How Would You Like Us to Handle Your Request
Enclosed the £10 statutory fee
Enclosed a clear certified copy of valid Photographic ID – i.e. Passport, Drivers Licence. Enclosed Proof of address (bank statement, or a utility bill, dated within the last three months) Signed Section 4 of this form
Enclosed the £75 initial fee
Enclosed a clear certified copy of valid Photographic ID – i.e. Passport, Drivers Licence.
Enclosed Proof of address (bank statement, or a utility bill, dated within the last three months)
Enclosed a signed Consent Form
Enclosed Insurance Company/ Solicitor details Signed Section 4 of this form
We require information about the insurance company/solicitor you would like to represent you. Any information we hold will then be released to them on your behalf.
I ………………………… authorise …………………………. to be provided with the recorded information regarding myself held by Penkridge Parish Council under the GDPR 2018.
Signed (individual): ……………………………. Date: …………………………..
Section Three
Fields marked* are mandatory Insurance Company/Solicitor*
Named Contact (If known)
Policy Number/ Case Reference Number*
Street Name*
Town*
Postcode*
Email Address (Optional)
Please note: that the £10 fee is non-refundable as it is required by the Parish Council for conducting a search
Data Subject Declaration
In exercise of the right granted to me under the terms of the GDPR 2018, I request that you provide me with a copy of the personal data about me which you process for the purposes I have indicated above. I confirm that the above is all of the personal data to which I am requesting access and which is held by the Council for its purposes. I also confirm that I am the subject of this information and not someone acting on my behalf. I understand that this request is subject to a £10 fee.
Signed ……………………………. Date ………………………..
Please return completed forms to:
Parish Administrator
Penkridge Parish Council
Haling Dene Centre
Cannock Road
Penkridge
Stafford ST19 5DT
Email: clerk@penkpc.co.uk
Section Four: Declaration
