Section 726.APPENDIX A Request for Public Records

TO:	Freedom of Information Officer	FROM:
	Illinois Department on Aging		NAME
	421 East Capitol Avenue		NAME
	Springfield, Illinois 62706		ADDRESS
			ADDRESS

			PHONE NUMBER

DESCRIPTION OF REQUESTED RECORD(S):

Please indicate if you wish to inspect the above captioned records or wish a copy of them:

	Inspection	Copy		Both
Do you wish to have copies certified?

FOR OFFICE USE ONLY:
Date Received			Date Response Due

Notations re Oral Communications or Other Items: