Form

OPEN RECORDS REQUEST FORM

Your name:	Street address:

City	State	Zip code

Home Phone	Alternative Phone	Fax Number

Your email address	Confirm your email address

In completing this request, please be exact and provide as much information as possible such as date (or time period involved) time, location, names of persons involved etc.

Under the authority of the Public Information Act, I request the following information:

Please fill out the contact numbers where you are readily available. A governmental agency has the right to request clarification if a request is too vague. We must also be able to obtain a valid fax or mailing address so we can forward an estimate of the cost of producing the requested material, if that cost exceeds $40.00.