FREEDOM OF INFORMATION ACT (FOIA) REQUEST FORM
**Note to Requester: PLEASE WRITE LEGIBLY. Retain a copy of this request for your files. If you eventually need to file a Request
for Review with the Public Access Counselor, you will need to submit a copy of your FOIA request. The Lake County Health
Department and Community Health Center will respond to your request within five business days. Response time may be
extended an additional five business days under the Illinois Freedom of Information Act Statute. Fees will be assessed in
accordance with the statute and requester will be notified prior to a response if there are fees due.**
Da
te of Request: ____________________
Submitted via: Email ______ Mail ______ Fax ______ In Person ______
Na
me
(first & last): __________________________________________________________________________________
Address
(#, street, city, st, zip): _________________________________________________________________________
Phone #’s: __________________________________________________ Fax: ____________________________
Email
(required to receive records via email): _______________________________________________________________
Rec
ords Requested:
*Provide as much specific detail as possible so the public body can identify the information you are seeking.
You may attach additional pages, if necessary.
_______
___________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Site Address / PIN Number (If applicable): _______________________________________________________________
How do you wish to receive the response? Email ______ Mail ______ Fax ______ Pick Up In Person ______
Is this request for a Commercial Purpose? YES_____ NO _____
(It is a violation of the Freedom of Information Act for a person to knowingly obtain a public record for a commercial purpose
without disclosing that it is for a commercial purpose, if requested to do so by the public body. 5 ILCS 140.3.1(c)).
Are
you requesting a fee waiver? YES_____ NO_____
(If you are requesting that the public body waive any fees for copying the documents, you must attach a statement of the purpose of
the request, and whether the principal purpose of the request is to access or disseminate information regarding the health, safety
and welfare or legal rights of the general public. 5 ILCS 140/6(c)).
(For Office Use Only)
Da
te Request Received: _____________________________ Date Response Due: ____________________________
Notes: ____________________________________________________________________________________________
__________________________________________________________________________________________________
Reviewed & Approved By: _____________________________________________ Date: ____________________
Waukegan, IL 60085
Phone: 847.377.8000
FOIA Fax: 847.984.5731
E-mail: HealthFoia@lakecountyil.gov
www.lakecountyil.gov/health
