Version 4. April 2013
GRAMA - Records Request Form
To: _____________________________________________________________________________________________
(Name of county agency/office holding the records and name of contact person if known)
Address of county agency: __________________________________________________________________________
Description of records requested: (Be as specific as possible; type of records, subject, year or dates wanted, etc.)
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Check all that are applicable:
___ I would like to review/inspect the records.
___ I would like to receive copies of the records. I understand that I will be responsible for copy costs. I authorize
costs of up to $__________. I understand that prepayment of copies over $50.00 may be required and that I will
be contacted if estimated costs are greater than the above specified amount.
___ I would like to receive copies of the records and request a waiver of costs under UCA 63G-2-203(4). Supporting
documentation is attached.
If the requested records are not Public, please explain why you believe you are entitled to access.
___ I am the subject of the record. (Photo ID required)
___ I am the person who submitted the record (Photo ID required)
___ I am authorized to access the record by the subject of the record.
(Consent for Release Form attached).
___ Other. Please explain. ______________________________________________________________________
___ I am requesting an expedited response as permitted by UCA 63G-2-204(3)(b). (Please attach information
showing status as a member of the media and a statement that the records are required for a story for broadcast
or publication, or other information demonstrating entitlement to an expedited response.)
Name of requester:________________________________________________________________________________
Street Address: ___________________________________________________________________________________
City: __________________________________________ State: ___________________ Zip Code: ________________
Daytime phone number where requestor can be reached: __________________________________________________
Email:___________________________________________________________________________________________
Signature: _______________________________________________________________ Date:____________________
Please note: state law does not require any agency to create any record to fulfill a request. GRAMA
applies only to existing records.
In some cases, you may need to provide a Social Security Number or other personal identifier to retrieve
records. In the case of a request for medical records, the agency may require you to complete a HIPAA
release.
DO NOT include your Social Security Number on this form. The agency will provide a separate method
for you to provide that number if it is needed.
