Public Information Request

Request Form for Copies or Reproduction of Public Record

Description of Record:

Date of Record (best estimate):

Public Agency or board having custody of record:

Name/address/telephone number of person requesting records:

Name:

Address:

Phone Number:

I agree to pay the actual cost of searching, reviewing, duplicating, and/or mailing copies of the requested public records, estimated to be $ .

Signature of Person Requesting Record:

Date:

Clerk's Acknowledgement

I acknowledge receipt of $__________ from above individual payment in full for the cost of searching, reviewing, duplicating, and/or mailing the requested records.

Date: __________

Clerk: __________________________