Revised 9/7/2017
Office of Lieutenant Governor Suzanne Crouch
ACCESS TO PUBLIC RECORDS REQUEST
Return to:
General Counsel
Office of Lieutenant Governor
Statehouse, Room 333
Indianapolis, IN 46204
publicrecords@lg.in.gov
Fax: (317) 233-6887
NAME OF REQUESTING PARTY: ______________________________________________
COMPANY (if applicable): _____________________________________________________
ADDRESS: __________________________________________________________________
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PHONE NUMBER: (____) _____________________________
EMAIL:
DATE: ______________________ TIME (if requesting in person): ___________________
IDENTIFY WITH REASONABLE PARTICULARITY THE RECORDS REQUESTED:
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REASON FOR REQUEST (OPTIONAL- FOR CLARIFICATION PURPOSES):
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NOTE: If the request exceeds 40 copied pages, $0.10 will be charged per page payable by check or cash.
Electronic records may be available at no charge. Please include your email address if you wish to receive
electronic records.
Inter-Office Use Only
Date Request Received: __________________ Date Request Denied (if applicable): _________________
Employee Handling Request: ______________ Reason Request Denied (if applicable): _______________
Amount Charged (if applicable): ___________ Date Request Fulfilled: ___________________
Date Agency responded: _________________ Payment Collected and Processed: __________
