Fillable Form 62: FOIA Request for Public Records Pittsfield (Pittsfield Charter Township)

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Form 62: FOIA Request for Public Records Pittsfield (Pittsfield Charter Township)

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Pittsfield Charter Township
62
01 West Michigan Avenue, Ann Arbor, MI 48108
Phone:
(734)
822-3120 Fax: (734) 944-8024
Website: www.pittsfield-mi.gov
Email to: clerk@pittsfield-mi.gov
Twp. Request
No._____________
FOIA Request for Public Records
Michigan Freedom of Information Act, Public Act 442 of 1976, MCL 15.231, et seq.
Name:
Date:
Firm/Organization:
Phone:
Address:
Direct:
City
State:
Zip:
Fax:
Email:
Request for: Copy Certified Copy Record inspection Subscription to record issued on regular basis
Delivery Method: Email Fax In-Person Mail Phone Deliver on digital media provided by the township: _____
Note: The Township is not required to provide records in a digital format or on digital media if the township 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:
To be completed at time of receipt:
Requestor’s Signature:
Date:
Consent to Non-Statutory Extension of Township’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 township 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 township’s response time for this request until: ________________ (month, day, year).
Requestor’s Signature:
FOR OFFICE USE:
Date Received: ______________
Need By Date: ______________
Date delivered to junk/spam folder: ___________________
Date discovered in junk folder: ___________________
Department Assigned: ______________________________________________________________
Received By: Email Fax In Person Other Electronic Method Mail
Completed Date: _______________ Notified By: ________________ Email Fax In Person : Phone : Mail
Delivered Date: _______________ Delivered By: Email Fax In Person Phone Mail
Twp. Request
No._____________
Records Located on Website
If the township 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 township 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 township 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 township 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 township
must provide the public records in the specified format (if the township 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 Township Website
I hereby stipulate that, even if some or all of the records are located on a township website, I am requesting that the township
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 township 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 township’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:
(A) The individual has previously received discounted copies of public records from the same public body twice during that
calendar year,
(B) 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
Requestor’s Signature: Date:
Twp. Request
No._____________
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:
1. Is made directly on behalf of the organization or its clients.
2. 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.
3. Is accompanied by documentation of its designation by the state, if requested by the township.
Office Use:
Affidavit 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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Form 62: FOIA Request for Public Records Pittsfield (Pittsfield Charter Township)

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Completed 19 January 2021

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