Date Requested:  __________________

Request Submitted by:____ E-Mail ____ US Mail ____ Fax ____ In-Person

Name of Requestor (Optional):  _____________________________________

Street Address (Optional):  _________________________________________

City/State/County (Required):  ______________________________________

Records Requested (Provide as much specific detail as possible so the agency can identify the information):

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

Do you want copies?  Yes or No __________

Do you want to inspect Records?  Yes or No __________

Do you want certified copies of Records?  Yes or No __________

Open Records Officer:  Kim Benjamin

Date Received by the Agency:  _____ / _____ / _____

*** Public bodies must fill anonymous verbal or written requests.  If the requestor wishes to pursue the relief and remedies provided for in the 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).