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Name of Agency
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City
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INSTRUCTIONS:
Requestor should fill out
the request portion (the top half) and sign the Requestor's Signature block.
Send copies 1 and 2 to the Agency. Keep the 3rd copy for references. Send no
money at this time. Unless notified otherwise the Agency's response for
APPROVED, DENIED or DEFERRED will be sent back within 7 working days after
receipt of the form.
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Address
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Requestor's Name (or
business name if applicable)
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Date of Request
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Phone Number
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Street Address
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CERTIFICATION REQUESTED YES
NO
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Requestor's Signature
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City
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State
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Zip
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DESCRIPTION OF RECORDS
REQUESTED:
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REQUESTING
COPIES
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TO INSPECT
RECORDS
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AGENCY RESPONSE (REQUESTOR
DOES NOT FILL IN BELOW THIS LINE)
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APPROVED
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The documents requested are
enclosed.
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The documents will be made
available upon payment of copying costs ....................................... $_____________
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You may inspect the record
at
___________________________________________________________________________
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on the date of
______________________.
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DENIED
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The request creates an undue
burden on the public body in accordance with Section 3(f) of the Freedom of
Information Act, and we are unable to negotiate a more reasonable request.
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The materials requested are
exempt under Section 7____ of the Freedom of Information Act for the
following reasons:
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INDIVIDUAL(S) THAT
DETERMINED REQUEST TO BE DENIED
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RIGHT TO APPEAL
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If desired, submit the
attached APPEAL form (No. 2) along with copies of the original REQUEST and
reasons for appeal to:
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DEFERRED
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Request delayed,
for the following reasons (in accordance with 3(d) of the DOIA):
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You will be notified by the
date of ___________________________ as to action taken on your request.
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The information required by
this form is MANDATORY in order to comply with P.A. 83-1013. Failure to so
provide may result in this form not being processed. This form is approved by
the Form
Management Center.
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FOIA Officer
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Date of Reply
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IL-001 – 0005 (6/84)
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LEGEND FOR REQUESTOR: 1st
copy (white) – send to Agency; 2nd copy (yellow) – send to Agency; 3rd copy
(pink) – Requestor's copy
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