Revised: July 2015
TOWN OF CULPEPER
400 S. MAIN STREET CULPEPER VIRGINIA 22701
540-829-8240
I, , hereby certify that I am a citizen of the C
ommonwealth of
Virginia or a representative of one of the public media having circulation in the Commonwealth, and hereby
request to inspect and/or copy the following official records pursuant to the Virginia Freedom of Information Act.
The request must be made with reasonable specificity.
__________________________________________________________________________________________
__________________________________________________________________________________________
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The requestor understands he/she will be responsible for paying the Town’s reasonable charges not to exceed its actual cost in copying and
searching for records. If the charge for providing the requested records is likely to exceed $200, you may be required to pay a deposit in
advance up to the estimated cost. The public body will produce the requested documents within five (5) working days, although simple
requests can be processed sooner and some requests may require additional time.
Date: Contact Information: ______________________________
FOR OFFICE USE ONLY
Request Received: By:
Date and Time
Standard Copies:
______________
pages at $.10/page $
______________
(two-sided documents are considered two pages)
Search Fee: $_________* per hour (first 15 minutes free) $
*Fee based on actual cost of person performing the search and compilation
Estimated cost: $ _____________________ Deposit paid: $_______________
Total charges to be paid to Town Treasurer: $_________________
I have received the requested documents on this ____day of , 20 ,
at a.m./p.m.
____________________________
Recipient
REQUEST FOR OFFICIAL RECORDS UNDER THE
FREEDOM OF INFORMATION ACT
Please check an option: _____________________________________
_____ I authorize charges up to $_____________. _______________________________
_____ Notify me of all charges before copying. _______________________________
