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 3^rd copy for reference. 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 this form.

Name of Agency

City

Address

Requestor's Name (Or business name if applicable)

Date of Request

Phone Number

Street Address

CERTIFICATION REQUESTED

  YES

   NO

City

State

Zip

Requestor's Signature

DESCRIPTION OF RECORDS REQUESTED

REQUESTING COPIES

TO INSPECT RECORDS

AGENCY RESPONSE (REQUESTOR DOES NOT FILL IN BELOW THIS LINE)

APPROVED

The documents requested are enclosed.

The documents will be made available upon payment of copying costs.......................................... $________

You may inspect the records at ___________________________________________________________ on the date of ___________________________.

DENIED

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.

The materials requested are exempt under Section 7 ___ of the Freedom of Information Act for the following reasons:

INDIVIDUAL(S) THAT DETERMINED REQUEST TO BE DENIED

RIGHT TO APPEAL

If desired, submit the attached APPEAL form (No. 2) along with copies of this original REQUEST and DENIAL and reasons for appeal to:

DEFFERED

Request delayed, for the following reasons (in accordance with 3(d) of the FOIA):

You will be notified by the date of _______________________________ as to action taken on your request.

The information required by this form is MANDATORY in order to comply with PA 83-1013. Failure to so provide may result in this form not being processed.  This form is approved by the Forms Management Center.

FOIA Officer

Date of Reply