Freedom of Information Act Request Form
Office of the Illinois Secretary of State
Executive Counsel
17 N. State St., Ste. 1179
Chicago, IL 60602
312-814-5535
312-814-0048 (fax)
www.cyberdriveillinois.com
Date _________________________________________________________________________________
R
equestor’s Name _______________________________________________________________________
Company______________________________________________________________________________
Address _______________________________________________________________________________
City, State, ZIP Code ____________________________________________________________________
Telephone Number ______________________________________________________________________
Requestor’s Email Address ________________________________________________________________
RECORDS SOUGHT: Mark records requested below. Please be specific.
❑ Printed records:___________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
❑ Electronic data processing records (specify format):
❏ Computer output tape ❏ CDrom: _______________ ❏ Other_________________________________
❑ Data fields (e.g. name): _______________________________________________________________________________
❑ Special run instructions: _______________________________________________________________________________
Requestor’s Signature __________________________________________________________________________________________
Return completed FOIA Request Form to: Illinois Secretary of State, Executive Counsel, 17 N. State St., Ste. 1179, Chicago, IL 60602;
fax to 312-814-0048; or e-mail to dleonard@ilsos.gov.
If your request is denied, you may file an appeal to: Public Access Bureau, Illinois Attorney General, 100 W. Randolph, 12th Fl.,
Chicago, IL 60601.
____________________________________________________________________________________________________________
(FOR DEPARTMENT USE ONLY)
RESPONSE:
Records made available: ❑ Date___________________________________________
Request denied, and reason: ❑ _______________________________________________
❑ _______________________________________________
Copies made: ❑ Yes ❑ No
Number ______________ ❑ Media Exemption
Fee paid $_____________
Other (attach correspondence):
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Printed by authority of the State of Illinois. May 2019 — 1 — EX 27.1
Date Stamp Receipt
