1     date

DD/MM/YYYYY

2     reference / case number

3     request status

r New request   

r Extension of previous request      r Ticket/reference number of previous request:

4     REQUESTED AUTHORITY

5     REQUESTING Authority *

Organisation

Person in charge of the request

Address

Telephone number

Cell phone number

E-mail address

Fax number

Office Hours

Time Zone

r

Response by email or other expedited means preferred

r

Response preferred by means of:

6     SHOULD ADDITIONAL confirmation FROM THE requesting authority be needed, PLEASE CONTACT:

Name:

Job Title:

Function:

Telephone number

Cell phone number

E-mail address

7     Investigative/Operational AUTHORITY in charge of the case

(if different from Requesting Authority)

Organisation

Person in charge at the authority

Address

Telephone number

Cell phone number

E-mail address

Fax number

8       prosecution office or Court in charge if applicable

Prosecution office in charge and case number

Court in charge and case number

Prosecution or Court decisions related to the request

9     FOLLOW UP THROUGH MUTUAL LEGAL ASSISTANCE

r

Please be informed that we intend to submit a request for mutual legal assistance to request the production of data.*

r

Please find enclosed a mutual legal assistance request for the production of data.

10  OFFENCES SUBJECT TO CRIMINAL INVESTIGATION OR PROCEEDINGS*

r Offence/s corresponding to Articles 2 through 11 Budapest Convention

Please specify offence under the law of the requesting State:

r Other offence/s

Please specify under the law of the requesting State:

11  summary of the case*

Including:

- brief description of the facts

- how the data sought is related to the investigation/offences

- purpose and necessity of request for preservation and/or partial disclosure of traffic data

- charges pressed/list of offences in the case

12  data to be preserved*

r Subscriber information

Please specify:

Period of interest

Start date: DD/MM/YYYY                       End date: DD/MM/YYY

Time (and time zone):                         Time (and time zone):

r If the system is a shared system, please preserve all basic subscriber information for all virtual systems on the IP.

r Traffic data

Please specify:

Period of interest

Start date: DD/MM/YYYY                       End date: DD/MM/YYYY

Time (and time zone):                         Time (and time zone):

r Content data

Please specify:

Period of interest

Start date: DD/MM/YYYY                       End date: DD/MM/YYYY

Time (and time zone):                         Time (and time zone):

13  information identifying the person or organisation (e.g. Service provider) in possession or control of the stored computer data AND The location of the computer system, IF AVAILABLE*

14  EXPEDITED DISCLOSURE OF PRESERVED TRAFFIC DATA UNDER ARTICLE 30 OF THE CONVENTION ON CYBERCRIME

Details/description of data to be disclosed[2]

r This request seeks to preserve traffic data concerning a specific communication.  If, in the context of this request, the server reveals that a service provider in another jurisdiction was involved in the transmission of this communication, please immediately disclose to us the identity of that service provider and the path of the communication in line with Article 30 of the Convention on Cybercrime.

15  CASE STATUS

r Pre-trial phase

r On trial        

r Crime in progress   

Other details if necessary:

16  Urgency

r URGENT

Response expected by: DD/MM/YYYY

REASONS FOR URGENCY

r Threat to life and limb

r Imminent threat of a serious nature to public security      

r Crime in progress    

r Suspect/offender in custody  

r Suspect/offender about to be released from custody

r Volatility of data

r Statute of limitation due to expire  

r Trial is imminent or in progress

r Other:

Brief details for urgency, if any

17  CONFIDENTALITY

r We request that that this preservation request is kept confidential and that customers are not notified. 

Please inform us if your domestic law requires us to explain the reason for confidentiality; or – before taking any action – whether your domestic law requires customer notification or if you suspect that the provider may not comply with the request for confidentiality.

18  Confirmation/notification requested, if available:

r Confirmation of receiving the request  

r Confirmation of preservation of the data

r Information on the preservation period  

r Information on whether data is beyond the jurisdiction of the requested country

r Information on whether the data preserved will be destroyed after the preservation period

r Other:

19  Additional NOTES, IF ANY

20  Signature and / or stamp of REQUESTING Authority if applicable

Name

Position

Date / place

Signature and/or stamp

21  Annex: Data specification form 

Please complete a separate form for each person or organisation believed to be in possession or control of data.  Please complete as much as is possible or applicable.

Details of person or organisation believed to be in possession or control of data

Business Name

Legal Name

Contact name

Address

Country

Phone

Email

Address

IPv4

1-255

1-255

URL

Date

Time

Time Zone

Proxy

Anonymization

Port number

IPv6

Subnet – 64 bit

Host – 64 bit

URL:

Date

Time

Time Zone

Proxy

Anonymization

Other data

E-mail address

Social Networking ID

Date

Time

Time Zone

Proxy

Anonymization