Date Appeal Received in State Agency

INSTRUCTIONS:

Requestor should fill out Sections – DESCRIPTION OF RECORDS, and REASONS FOR APPEALING. Send copies 1 and 2 to the Director of the Agency which original request was sent to. (The block for the Agency's name and address is aligned for window envelopes. Please use if appropriate.) Unless notified otherwise the Agency's response will be within 7 working days after receipt of appeal.

Requestor's Name (Or business name if applicable)

Send Appeal To:  (Director and Agency)

Street Address

Street Address

City

State

Zip

City

State

Zip

DESCRIPTION OF RECORDS THAT APPEAL IS BEING MADE FOR:

REASONS FOR APPEALING

DIRECTOR'S RESPONSE TO APPEAL

Noted below is the action I have taken on your appeal from the denial of your request for the above captioned records.

I hereby approve your appeal to the following extent and for the following reasons:

I affirm the denial of your request made by the Freedom of Information Officer.

Note: You are entitled to judicial review of any denial pursuant to Section 11 of the Freedom of Information Act.

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 Forms Management Center.

Director's Signature

Date of Reply