CHAUTAUQUA COUNTY
APPLICATION FOR PUBLIC ACCESS TO RECORDS
TO: CHAUTAUQUA COUNTY LAW DEPARTMENT
GERACE OFFICE BUILDING
3 NORTH ERIE STREET
MAYVILLE, NY 14757
This form is provided only as a convenience. No particular form of request is
required by law. Your request must be in writing. Pursuant to applicable
provisions of law, access to some or all of the records may be denied.
<<<PLEASE PRINT LEGIBLY SO THAT WE MAY ASSIST YOU ACCORDINGLY>>>
Identify records and/or reasonably describe documents you are interested in as clearly as possible.
I hereby apply to access the following record(s) ___________________________________________________
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__________________________________________________________________________________(Over…)
□ I hereby request to inspect the record(s) in person.
□ I hereby request a copy of the record(s), for which I agree to pay $.25 per page.
□ If available in electronic format, I request the record(s) electronically at no charge.
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Email Address
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Name (Required) Signature (Required)
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Telephone Number Date (Required)
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Mailing Address
NOTICE: The Freedom of Information Law also stipulates that certain information can be denied, however, the
County is required to advise you of your rights to appeal such denials. If you choose to appeal a denial of
information, you must do so in writing within 30 days of receipt of such denial. The appealing authority is
Chautauqua County Executive, 3 N. Erie Street, Mayville, New York 14757. Your appeal must state the date of
the denial, the information requested, the information denied, and the reason for the denial.
