Section 1901.APPENDIX A Request for Public Records

TO: Freedom of Information Officer Illinois Health Facilities Authority 180 North Stetson Avenue, Suite 1100 Chicago, Illinois 60601		FROM:
			Name
			Address
			ZIP ( )
			Telephone
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
FOR OFFICE USE ONLY:
Date Received			Date Response Due

(Source: Amended at 20 Ill. Reg. 358, effective December 26, 1995)