Fillable CITY OF HOPKINSVILLE OPEN RECORDS REQUEST FORM SPECIFIC

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CITY OF HOPKINSVILLE OPEN RECORDS REQUEST FORM SPECIFIC

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CITY OF HOPKINSVILLE
OPEN RECORDS REQUEST FORM
Name: ____________________________________________________________________________
Mailing address: ____________________________________________________________________
Phone number: _____________________________________________________________________
Fax number: _______________________________________________________________________
SPECIFIC RECORD(S) REQUESTED (Indicate whether you are requesting copies or to review the
records. If this is not indicated it will be assumed you are requesting copies.)
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Select one: This must be completed.
Request is for □ noncommercial OR □ commercial purpose.
I hereby certify the information provided in this request is true and accurate.
_____________________________________ _________________________________________
Signature Printed Name
A PERSON WHO VIOLATES KRS 61.874 (INDICATING WHETHER RECORDS ARE
REQUESTED FOR COMMERCIAL OR NONCOMMERCIAL PURPOSE) SHALL BE LIABLE
TO THE CITY FOR DAMAGES, COSTS, AND PENALTIES TO THE AMOUNT
ESTABLISHED BY LAW
Return completed application to:
City Clerk
City of Hopkinsville
715 S. Virginia Street
Hopkinsville, Kentucky 42240
Fax: (270) 632-2056
CITY USE ONLY
Date received: ____________________________________ By: _______________________________
Latest date to respond: _____________________________ Date responded: ____________________
Fees Charged:
Photocopies __________________
Media __________________
Postage __________________
Staff* __________________ *only for commercial requests or body camera videos
Other __________________
TOTAL __________________
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CITY OF HOPKINSVILLE OPEN RECORDS REQUEST FORM SPECIFIC

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Completed 23 January 2021

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