City of Adrian
135 East Maumee Street
Adrian, Michigan 49221
Phone: (517) 264-4815
FOIA Request for Public Records
Michigan Freedom of Information Act, Public Act 442 of 1976, MCL 15.231, et seq.
Request No.: __________ Date Received: ___________ Check if received via: Email Fax Other Electronic Method
Date delivered to junk/spam folder: _______________
(Please Print or Type) Date discovered in junk/spam folder: _______________
Request for: Copy Certified copy Record inspection Subscription to record issued on regular basis
Delivery Method: Will pick up Will make own copies onsite Mail to address above Email to address above
Deliver on digital media provided by the City: ________________________________________________________________
Note: The City is not required to provide records in a digital format or on digital media if the City does not already have the
technological capability to do so.
Describe the public record(s) as specifically as possible. You may use this form or attach additional sheets:
Consent to Non-Statutory Extension of City’s Response Time
I have requested a copy of records or a subscription to records or the opportunity to inspect records, pursuant to the Michigan Freedom of
Information Act, Public Act 442 of 1976, MCL 15.231, et seq. I understand that the City must respond to this request within five (5) business days
after receiving it, and that response may include taking a 10-business day extension. However, I hereby agree and stipulate to extend the City’s
response time for this request until: ________________ (month, day, year).
Requestor’s Signature Date
Name Phone
Firm/Organization Fax
Street Email
City State Zip
(Complete both sides)
City: Keep original and
provide copy of both sides,
along with Public Summary,
to requestor at no charge.
Request Form
Note: Requestors are not
required to use this form. The
City may complete one for
recordkeeping if not used.
Records Located on Website
If the City directly or indirectly administers or maintains an official internet presence, any public records available to the general public on that internet
site at the time the request is made are exempt from any labor charges to redact (separate exempt information from non-exempt information).
If the FOIA coordinator knows or has reason to know that all or a portion of the requested information is available on its website, the City must notify
the requestor in its written response that all or a portion of the requested information is available on its website. The written response, to the degree
practicable in the specific instance, must include a specific webpage address where the requested information is available. On the detailed cost
itemization form, the City must separate the requested public records that are available on its website from those that are not available on the
website and must inform the requestor of the additional charge to receive copies of the public records that are available on its website.
If the City has included the website address for a record in its written response to the requestor and the requestor thereafter stipulates that the public
record be provided to him or her in a paper format or other form, including digital media, the City must provide the public records in the specified
format (if the City has the technological capability) but may use a fringe benefit multiplier greater than the 50%, not to exceed the actual costs of
providing the information in the specified format.
Request for Copies/Duplication of Records on City Website
I hereby stipulate that, even if some or all of the records are located on a City website, I am requesting that the City make copies of those records on
the website and deliver them to me in the format I have requested above. I understand that some FOIA fees may apply.
Requestor’s Signature Date
Overtime Labor Costs
Overtime wages shall not be included in the calculation of labor costs unless overtime is specifically stipulated by the requestor and clearly noted on
the detailed cost itemization form.
Consent to Overtime Labor Costs
I hereby agree and stipulate to the City using overtime wages in calculating the following labor costs as itemized in the following categories:
1.
Labor to copy/duplicate 2. Labor to locate 3a. Labor to redact 3b. Contract labor to redact
6b.
Labor to copy/duplicate records already on City’s website
Requestor’s Signature
Date
Request for Discount: Indigence
A public record search must be made and a copy of a public record must be furnished without charge for the first $20.00 of the fee for each
request by an individual who is entitled to information under this act and who:
1) Submits an affidavit stating that the individual is indigent and receiving specific public assistance, OR
2) If not receiving public assistance, stating facts showing inability to pay the cost because of indigence.
If a requestor is ineligible for the discount, the public body shall inform the requestor specifically of the reason for ineligibility in the public body's
written response. An individual is ineligible for this fee reduction if ANY of the following apply:
(i) The individual has previously received discounted copies of public records from the same public body twice during that calendar year,
(ii) The individual requests the information in conjunction with outside parties who are offering or providing payment or other remuneration
to the individual to make the request. A public body may require a statement by the requestor in the affidavit that the request is not being
made in conjunction with outside parties in exchange for payment or other remuneration.
Office Use: Affidavit Received Eligible for Discount Ineligible for Discount
I am submitting an affidavit and requesting that I receive the discount for indigence for this FOIA request:
Requestor’s Signature:
Date:
Request for Discount: Nonprofit Organization
A public record search must be made and a copy of a public record must be furnished without charge for the first $20.00 of the fee for each
request by a nonprofit organization formally designated by the state to carry out activities under subtitle C of the Developmental Disabilities
Assistance and Bill of Rights Act of 2000 and the Protection and Advocacy for Individuals with Mental Illness Act, if the request meets ALL of the
following requirements:
(i) Is made directly on behalf of the organization or its clients.
(ii) Is made for a reason wholly consistent with the mission and provisions of those laws under section 931 of the Mental Health Code,
1974 PA 258, MCL 330.1931.
(iii) Is accompanied by documentation of its designation by the state, if requested by the City.
Office Use: Documentation of State Designation Received Eligible for Discount Ineligible for Discount
I stipulate that I am a designated agent for the nonprofit organization making this FOIA request and that this request is made
directly on behalf of the organization or its clients and is made for a reason wholly consistent with the mission and provisions of
those laws under section 931 of the Mental Health Code, 1974 PA 258, MCL 330.1931:
Requestor’s Signature:
Date:
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