Fillable Form 1 - Application for Access to a

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Form 1 - Application for Access to a

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Country of origin: CANADA
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Page 1 of 3
Form 1 - Application for Access to a Record
Part XX - Freedom of Information and Protection of Privacy
Municipal Government Act
Attn: Access & Privacy Office
Halifax Regional Municipality
P. O
. Box 1749, Halifax, NS, B3J 3A5
Duke Tower, 5251 Duke St, 7th Floor, Halifax, NS B3J 1P3
Mailing Address:
Delivery Address / Drop Box:
Phone:
Email:
902-943-2148
access@halifax.ca
Section 1: Type of Request
This is an application pursuant to Part XX of the Municipal Government Act (Freedom of Information and Protection of
Privacy) for access to (check one):
Personal - Applicant’s own personal information (Application fee - No cost)
General - Other Information ($5.00 application fee - mandatory)
Combination of Personal & General ($5.00 application fee - mandatory)
** Please note: According to Part XX, Section 461(f) of the Municipal Government Act, personal information may include but is not limited to:
individual’s name, address or telephone number; race, sex, sexual orientation, marital or family status; information about individual’s health-care
history, including a physical or mental disability; and/or information about the individual’s educational, financial, criminal or employment history.
Section 2 - Description of Records Requested
* Please describe the records you are looking for as precisely as possible.
** If you are requesting property related records, we will process one civic address per application.
I am applying for access to the following record(s):
If known, which municipal department has the
records you are requesting:
If applicable, for what date range would you like us
to conduct a search for the records requested:
From (MM/DD/YY):
To (MM/DD/YY):
If known, please specify any reference or file
number associated to the records requested:
Section 3 – Record Format Requested
I wish to receive the record(s) requested in the following format (check one):
Examine the record(s)
Receive copy of the record(s)
Receive an electronic copy of the record(s) if possible.
** Note: electronic records are typically provided in pdf or excel format and depending on file(s) size, they may be emailed or for an additional fee,
saved to disk/flash drive.
Section 4 – Contact Information
Mr.
Ms.
First Name:
Last Name:
Mrs.
Miss.
Street No.:
Suite/Unit No.:
City/Town:
Province:
Postal Code:
Phone (Res):
Phone (Bus):
Phone (cell):
Fax No.
Email:
Signature:
Date (MM/DD/YYYY):
Section 5: Payment of Application Fee
$5.00 cheque or money order payable the Halifax Regional Municipality (HRM) is enclosed.
I will make payment by cash or debit at a municipal customer service centre.
** The locations and hours of operation can be found on our municipal website
.
Once your application form is received by email or fax we will provide you with the file number assigned to your
application. This number should be provided to the agent at the customer service centre when making payment. A
copy of your receipt will be forwarded to the Access & Privacy Office for your file.
Please note, submission of your application will not be considered complete until payment has been made.
Section 6 – Request to Waive Additional Fees (** see page 3 for summary of fees)
I hereby request to be excused from paying fees (other than the application fee which is mandatory for General or
Personal/General request) that may be required in the processing of this application because:
I cannot afford to pay additional fees
Specify any other reason:
Collection & Use Disclosure Statement
In accordance with Section 485 of the Municipal Government Act, the personal information collected on this form will only be used and/or
disclosed if necessary, for the purpose of processing this Access to Information Application. If you have any questions about the
collection and use of this information, please contact HRM’s Access & Privacy Office at (902) 943-2148 or
privacy@halifax.ca.
Page 2 of 3
Page 3 of 3
Access to Information Request – Summary of Fees
Application Fee
Request for records personal in nature
N/A
Request for general records
$5.00
Request for a combination of personal and general records
$5.00
** For larger volume requests, the following are additional fees that may be charged for the processing
of anything above the initial 250 pages.
Processing Fees
Locating & Retrieving records
$15 per ½ hour
Record Preparation
(review of records and the severing of
information as dictated by legislation)
$15 per ½ hour
Photocopying
Black & White pages
$0.20/page
Colour pages
$0.30/page
Large/oversized drawings or plans
$5.00/plan
Shipping &
Handling
** For shipping a record, the fee will be the actual costs of shipping method chosen by
the applicant.
Cost Recovery
Flash Drive (if used for the release of electronic records/files
$7.00+tx ea.
** If electronic records are requested and an email address has been provided, we will
do our best to release the records via email correspondence however due to file(s) size if
we are unable to do so we will save electronic records to a flash drive.
** Please note, most our applications do not result in additional fees being charged, however if it is
determined that the volume of records requested necessitates a fee estimate, you will be advised
accordingly.
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Completed 8 February 2022

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