Fillable Mississippi Department of Education - Public Records Request Form

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Mississippi Department of Education - Public Records Request Form

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The Mississippi Department of Education - Public Records Request Form form is 1 page long and contains:

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Requesters Public Records Request/Report Information
Full Name: ____________________________________________________________________________
Last First M.I.
Organization: ____________________________________________________________________________
Address: ____________________________________________________________________________
Street Address
____________________________________________________________________________
City State Zip Code
Phone: ________________________________ Alternate Phone: _____________________________
Email: ____________________________________________________________________________
Information Requesting
I hereby request the following records maintained by the MS Department of Education. (Request shall
be specific enough to allow the Department employees to identify and retrieve records requested)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
My Request is to:
_____ 1. Review the records listed above
_____ 2. Receive copy (s) of records listed above
_____ 3. Mail copy (s) of records to address shown above
I understand that appropriate charges for searching, copying and/or mailing shall be paid in full prior to
granting this request. I acknowledge that the Mississippi Department of Education has a minimum of
seven (7) working days from the date of receipt to respond to my request in accordance with MS Public
Records Act § 25-61-1 seq.
Signature of person making request: ____________________________________________________
____________________________________________________
Title Date
MDE USE ONLY
Footprint Number: ___________________ Date Completed:_____________________________
Approved Denied
Office of Public Reporting: ☐ ☐ Initials__________ Date_____________
Legal: ☐ ☐ Initials__________ Date_____________
Cost: $_____________________ Date Payment Received:______________________________
Office of Public Reporting
PO Box 771
Jackson, MS 39205-0771
601-359-3857
Email: reporting@mdek12.org
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Mississippi Department of Education - Public Records Request Form

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Completed 24 May 2020

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