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Inspection/Duplication of Records Request
Tenn. Code Ann. § 10-7-503(a)(7)(A)
Form #CT-0445
Revised 12/10
INSPECTION/DUPLICATION OF RECORDS REQUEST
Requestor Instructions: To make a request for copies of public records fill in sections 1-5, and sign and date section 9 at
the time the request is made. Requestors who are retrieving the requested records from the office of the records custodian in
person should not sign and date section 11 until the records are received. Requestors who are having the records emailed or
mailed to him/her are not required to sign and date section 11 of the form.
Custodian Instructions: For requests to inspect, the records custodian is to fill in sections 1-6,8, and sign and date section
10 at the time the request is made. Section 12 should not be signed and dated until the requestor inspects the records. For
requests for copies or duplicates, the records custodian is to fill in sections 6-8 and sign and date section 10 at the time the
request is made. Section 12 should not be signed and dated until the records are retrieved by or delivered to the requestor.
Note: Tenn. Code Ann. § 10-7-503(a)(7)(A) provides that unless another provision in law specifically requires a written request, a
request to inspect public records may not be required to be in writing nor can a fee be assessed for inspection of records.
(FRONT)
1. Name of requestor: _______________________________________________________________________
(Print or Type; Initials of requestor are required for copy requests)
2. (If required) Form of identification provided:
Photo ID issued by governmental entity including requestor’s address
Other: _______________________________________________________________________
3. Requestor’s address and contact information: __________________________________________________
__________________________________________________________________________________________
4. Request for: inspection/access copy/duplicate [previously inspected on _______
(date) or
inspection waived]
5. Record(s) requested:
a. Type of record: Minutes Annual Report Annual Financial Statements
Budget Employee file Other
b. Detailed Description of the record(s) including relevant date(s) and subject matter:
__________________________________________________________________________________________
__________________________________________________________________________________________
6. Request submitted to: ____________________________________________________________________
(Name of Governmental Entity, Office or Agency)
a. Employee receiving request:_________________________________________________________
(Print or Type and Initial)
b. Date and time request received:_______________________________________________________
c. Response: Same day Other _____________________________________________________
7. Costs (if assessed):
a. Number of pages to be copied: _____________ Estimated
b. Cost
(1) per page letter or legal sized: $____(justification required if more than $0.15) per black and
white $_____(justification required if more than $0.50) per color;
(2) per page other sized or other medium__________________: $_____(justification required)
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Inspection/Duplication of Records Request
Tenn. Code Ann. § 10-7-503(a)(7)(A)
Form #CT-0445
Revised 12/10
Costs continued:
c. Estimate of labor costs to produce the copy (for time exceeding 1 hour): _____________________
Labor at $__________ /hour for _____________ hour(s).
Labor at $__________ /hour for _____________ hour(s).
Labor at $__________ /hour for _____________ hour(s).
d. Programming cost to extract information requested:___________________________
e. Method of delivery and cost:____________ Estimated
On-site pick-up U.S. Postal Service Other: ______________________
f. Estimate of total cost to produce request: ________________________
g. Estimate provided to requestor: in person by U.S.P.S. by phone Other:____________
8. Payment:
a. Form of payment: Cash Check Other________________________________________
b. Amount of payment: _______________________________________________________________
c. Date of payment: __________________________________________________________________
d. Actual cost (and adjustment if prepaid):_________________________________________________
9. _________________________________ _______________________________
Signature of Requestor Date Records Requested
10. _________________________________ _______________________________
Signature of Records Custodian Date of Receipt of Request
Delivery/Retrieval of Records
11. _____________________________________ ___________________________________
Signature of Requestor Date Records Retrieved
12. ______________________________________ ____________________________________
Signature of Records Custodian Date Records Retrieved/Delivered
Or
_____________________________________
Date Records Inspected by the Requestor