REQUEST FOR COPIES OF PUBLIC RECORDS UNDER THE
DATE:____________________________
NAME:______________________________________________________________________________
ADDRESS:___________________________________________________________________________
TELEPHONE:________________________________________________________________________
DESCRIPTION OF REQUESTED
RECORD(S):_____________________________________________
_____________________________________________________________________________________
Please indicate if you wish to inspect the above captioned records or wish a
copy of them.
_________Inspection _______Copy _______Both
Do you wish to have the copies certified? _____Yes_______No
I am not seeking the above captioned records for the purpose of furthering a commercial enterprise.
_______________________________________
SIGNATURE OF REQUESTER
_______________________________________________________
Office Use Only
__________________________ _______________________________
Date Received Date Response Due
Records Made Available _____yes_____no Copies Made ____yes _____no
Request Denied ______yes_____no How Many?_____ Fee_______
Reason Denied: _______________________________________________________________________
Signature:____________________________________ Date:_____________________________