City of Adrian
Freedom of Information Act Coordinator
135 East Maumee Street Request Number:_________
Adrian, Michigan 49221
Phone: (517) 264-4815
Fax: (517) 264-4164
REQUEST FOR DISCLOSURE OF RECORDS
By Authority of the Michigan Freedom of Information Act. 442, P.A. 1976, as amended.
ALL INFORMATION MUST BE TYPED OR PRINTED EXCEPT FOR WRITTEN SIGNATURE.
Requester’s Name:_____________________________________________________________________________
Address (Street and Number):___________________________________________________________________
City:______________________ State:________________ Zip Code:____________________
Home Phone:___________________________ Business Phone:____________________________________
Organization (if any):__________________________________________________________________________
Email Address:
I wish to: examine receive a copy of the following materials:
Please fill in as much information as possible:
Report No.:________________ Date of Incident (If unknown, as close as possible):______________
Type of Incident (Please Describe):_______________________________________________________________
Names of Individuals Involved:__________________________________________________________________
_____________________________________________________________________________________________
I hereby request a waiver or reduction in fees as provided in Section 4(1) of F.O.I.A. because:
I am indigent or receiving public assistance (proof attached)
I represent a public interest group (Attach statement fully explaining nature of organization)
I understand the City of Adrian may take an additional 10 business days, if necessary, to fill my request, due to the
diverse locations or large volume of the materials. I understand that if it is determined that some or all of the
materials which I have requested to review or have copied may not be disclosed I will receive a written denial
including the reason for denial and explaining my right to appeal.
If you have questions or concerns regarding this form or your request, please call Michelle Beddingfield at (517)
264-4815, or email your question to
cattorney@ci.adrian.mi.us
. Once you have submitted your form you will
receive a response within 5 business days. Please make sure you have included a phone number and/or email
address that we may contact you at.
Click the “SUBMIT” button to send your request.
