Fillable CITY OF DICKINSON Public Information/Records Request Form (City of Dickinson)

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CITY OF DICKINSON Public Information/Records Request Form (City of Dickinson)

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The CITY OF DICKINSON Public Information/Records Request Form (City of Dickinson) form is 1 page long and contains:

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  • 5 check-boxes
  • 12 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Dickinson

BROWSE CITY OF DICKINSON (TX) FORMS

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Form Updated July 5, 2016
CITY OF DICKINSON
Public Information/Records Request Form
Name: ____________________________________
Address: __________________________________
City: _____________________________________
State:_________ ZIP: ______________________
Telephone No.: _____________________________
Alternate No.: ______________________________
Specific Record(s) Requested:
(Please be as specific as possible so your request may be handled as quickly as possible)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Please specify how you would prefer to receive the records:
(Check one box)
☐ PICKED UP by me or my representative when you advise the information is ready
☐ EMAILED to me at:
☐ MAILED to me at the address indicated above.
☐ FAXED to me at:
☐ MADE AVAILABLE TO ME FOR EXAMINATION ONLY. The Records Manager may schedule an
appointment within a reasonable time for my examination of the information. I understand that
I must complete my examination within (10) days after the date the records are made available
to me.
I understand that every effort is made to expedite requests, but there may be occasions when records may
not be immediately available. I agree to pay the costs of photocopying, duplication, the labor costs involved in
retrieving information that is not readily available or is in need of redacting, and the cost of mailing or faxing
pursuant to Texas Government Code Chapter 552.
Signature of Requestor Date of Request
click to sign
signature
click to edit
Form Updated July 5, 2016
PUBLIC RECORDS CHARGES
Standard-Size Copy (up to and including 8.5 inches x 14 inches) reproduced by copier or computer printer
a) 50 pages or less of readily available information $ .10 per page (+10 pgs)
b) in excess of 50 pages of readily available information $ .85 first page
$ +.15 ea. Adtnl
c) non-readily available information $ + personnel costs
Nonstandard-Size Copy $ Actual cost
CD $ 1.00 ea.
DVD $ 2.50 ea.
Paper copy $ .50 ea.
Personnel Charge – Prorated $ 15.00/ hr ________
(Not charged for 50 or fewer readily available
standard size form, or time of an attorney,
legal assistant, or reviewer)
Overhead Charge $ 20% of total Personnel Charges _______
For non-readily available or in excess of 50 pages
Computer Resource Charge
Mainframe $ 17.50/ minute
Midrange $ 3.00/ minute
Client/ Server $ 1.00/ minute
PC or LAN $ .50/ minute
Remote Document Retrieval Charge $ Actual Cost
Programming Charge $ 26.00/ hr
Miscellaneous Supplies Charge $ Actual Cost
(Label, boxes, and other producing supplies)
Postal and Shipping Charge $ Actual Cost
Fax Charge
Local $ .10/ page
Long-distance – same area code $ .50/ page
Long-distance – different area code $ 1.00/ page
Inspection of Records
Standard – size form 50 or less readily available $ No Charge
Standard – sized form in excess of 50 readily available $ Assessed
Total Charges: _____________
Deposit (If estimated charges exceed $100.00): ½ Charges:
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CITY OF DICKINSON Public InformationRecords Request Form (City of Dickinson)

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Completed 18 January 2021

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