REQUEST FOR PUBLIC RECORDS
Requester’s Name: ___________________________________________________________________
Mailing Address: ___________________________________________________________________
Street City State Zip
Daytime Phone Number: ______________________ Email: _________________________________
Description of records requested. Please be as specific as possible. If known, include author, recipient, title, date or date range, etc.
List each Department, Office or Official having custody of the records requested, if known:
After the County retrieves the requested records, I request:
[ ] Inspection only [ ] Copy all [ ] Inspection, then copy selected pages.
Standard copies: 15 cents per page. Electronic record on CD-ROM or floppy disk: $5.00.
Audio cassette recordings: $10.00 per cassette. Mailing: actual cost, including cost of shipping container.
Payment: cash or check. There is no charge to inspect documents.
Date desired: __________________ Most requests are filled within five (5) business days.
If my request is for a list of individuals, I certify under penalty of perjury under the laws of the State of
________________ ___________________________________
Date Signature
Date Initials Date Request Received _____________ ______ 5-Day Notice Sent _____________ ______ Reviewed By Prosecutor _____________ ______ Request Approved _____________ ______ Request Denied _____________ ______ Requestor Contacted _____________ ______ 30-Day Notice Sent _____________ ______ Documents Delivered To Requestor _____________ ______ Request Closed _____________ ______For Use By Public Records Officer