2. Date Requested
   Date Requested
4. Request Submitted by:

   1. E-Mail
   2. U.S. Mail
   3. Fax
   4. In-Person
6. Request Submitted to:
   (Agency Name and Address)
8. Name of Requester:
10. Address
12. City
13. State
14. Zip Code
16. Telephone
    (Optional)
17. Email
    (Optional)
19. Records Requested:
    Provide as much specific detail as possible so the agency can identify the information. Please use additional sheets if necessary
21. Do You Want Copies?

    1. Yes
    2. No
23. Do You Want to Inspect the Records?

    1. Yes
    2. No
25. Do You Want Certified Copies of Records?

    1. Yes
    2. No
27. Do You Want to Be Notified in Advance if the Cost Exceeds $100?

    1. Yes
    2. No
29. ** Please Note: Retain a Copy of This Request for Your Files **
31. ** it is a Required Document if You Would Need to File an Appeal **
35. **Public bodies may fill anonymous verbal or written requests. If the requestor wishes to pursue the relief and remedies provided for in this Act, the request must be in writing. (Section 702.) Written requests need not include an explanation why information is sought or the intended use of the information unless otherwise required by law. (Section 703.)
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37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field