Fill and Sign the Records Request Open Act Form

Request for Public Records (Made pursuant to Open Records Act) Date       To: Public Records Custodian Name of Public Entity to whom request is delivered or mailed is:       Address:             City:       State:       Zip:       Open Records Request Pursuant to the open records laws of the State of       , the undersigned person, requests that the Custodian of Public records of the above named public entity, provide to the undersigned in compliance with such law, a COPY of the following specifc public records in the possession of the named public entity, or any agent thereof (if a copy is not available, please provide the original for copying or duplication): Record Requested ( description ):       Date of Record, if known:       Subject of Record:       Further description:             Record Requested ( description ):       Date of Record, if known:       Subject of Record:       Further description:             If additional records are requested, a listing of the records is attached. I understand that this Request for a copy of Public Records may be maintained as a portion of the public records and that allowing the inspection and copying of the requested public records does not waive or restrict any copyright, proprietary or other rights in said documents. I agree to pay for the allowed costs in providing the requested records, not to exceed       . If this cost will be exceeded, please contact the undersigned. I HAVE READ AND AGREE TO COMPLY WITH THE ABOVE CONDITIONS. Requested by: (Name Printed) (Signature) (Date) Address: __________________________________________________________________________________________________ Phone: ____________________________ Fax: _______________________________ Delivered by: Hand Delivered Regular Mail Certifed Mail Date Delivered: _________________________ Time Delivered: ________________________ FOR PUBLIC ENTITY USE ONLY RECORDS REVIEWED DATE RECORDS RELEASED Comments: _______________________________________________________________________________________________ Additional Records Requested: Record Requested ( description ):       Date of Record, if known:       Subject of Record:       Further description:             Record Requested ( description ):       Date of Record, if known:       Subject of Record:       Further description:             Record Requested ( description ):       Date of Record, if known:       Subject of Record:       Further description:             Record Requested ( description ):       Date of Record, if known:       Subject of Record:       Further description:             Record Requested ( description ):       Date of Record, if known:       Subject of Record:       Further description:             Record Requested ( description ):       Date of Record, if known:       Subject of Record:       Further description:             Record Requested ( description ):       Date of Record, if known:       Subject of Record:       Further description:             Record Requested ( description ):       Date of Record, if known:       Subject of Record:       Further description: