Fillable COY-Request-For-Public-Record-7.4 REQUEST FOR PUBLIC RECORDS

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COY-Request-For-Public-Record-7.4 REQUEST FOR PUBLIC RECORDS

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REQUEST FOR PUBLIC RECORDS
Office of the City Clerk, One City Plaza, P.O. Box 13012, Yuma, AZ 85366-3012
PHONE (928) 373-5035 ● FAX (928) 373-5036 ● TTY (928) 373-5149
City of Yuma
I (print name) hereby request the following City of
Yuma public record(s), for:
Review
Copies
STATEMENT OF PURPOSE
In accordance with the provision of Arizona Revised Statutes, Section 39-121.03, I state:
That copies, printouts, or photographs of City records which have been requested will not be
used for commercial purpose(s); or
____That copies, printouts, or photographs of City records which have been requested will be used
for commercial purpose(s):
___________________________________ ______________________________________
Signature and Date Phone Number
______________________________________
E-mail Address (optional)
The following public records were supplied per this request:
Office of the City Clerk, One City Plaza, P.O. Box 13012, Yuma, AZ 85366-3012
PHONE (928) 373-5035 ● FAX (928) 373-5036 ● TTY (928) 373-5149
For Office Use Only
REQUEST RECEIVED: RECORDS DISBURSED:
__________ copies @ $._______ per page Copy Charge $_____________
Copy charges:
Non-commercial purpose $.25 per page
Commercial purpose $.50 per page
City Council agenda items: $
-_______
If a request is made within seven (7) days prior to or three (3) days
after the date of the City Council meeting, there is no charge for the
first five (5) pages copied.
Staff time: Dept/Name: _________________________________ Time: ___________
Dept/Name: _________________________________ Time: ___________
Dept/Name: _________________________________ Time: ___________
Dept/Name: _________________________________ Time: ___________
Dept/Name: _________________________________ Time: ___________
$5.00 per audio tape or compact disc Audio Tape or CD Fee $_____________
$20.00 per video tape/DVD Video Tape/DVD Fee $_____________
$5.00 per certification Certification Fee $_____________
TOTAL $_____________
PAID INVOICE# _____________
2/07/08-sm
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COY-Request-For-Public-Record-7.4 REQUEST FOR PUBLIC RECORDS

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Completed 1 November 2019

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