Name of Agency

City

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.

Address

Requestor's Name (or business name if applicable)

Date of Request

Phone Number

Street Address

CERTIFICATION REQUESTED      YES      NO

Requestor's Signature

City

State

Zip

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 record 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 the original REQUEST and reasons for appeal to:

DEFERRED

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

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 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.

FOIA Officer

Date of Reply