REQUEST FOR DISCLOSURE OF DOCUMENTS
UNDER THE OPEN RECORDS ACT
VERBAL (TELEPHONE) VERBAL (WALK-IN) EMAIL MAIL OTHER _______________________________
Name of Requester: ___________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
______________________________________________________________________________________________________________
Phone: _______________________FAX:___________________EMAIL: ____________________________________________________
Pursuant to O.C.G.A. § 50-18-70 et seq., I am formally requesting to inspect certain public records. In particular, records requested for
inspection are: (YOU MAY UTILIZE BACK OF THIS FORM OR ATTACH ADDITIONAL PAPER IF NEED BE)
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Date records are requested to be made available: _____________________________________________________________________
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I agree to pay any copying and/or administrative costs incurred in fulfilling my requests to the extent permitted by Georgia law. Such costs
may include charges of $.10 (cents) per page and administrative charges for search, retrieval, and other direct administrative costs, such
administrative charges not to exceed the salary of the lowest paid full-time employee who, in the discretion of the custodian of the records,
has the necessary skill and training to perform the request. (The requester is not charged for the first fifteen minutes of time.)
Name (Print): ___________________________________________________________________________________________________
Signature: _____________________________________________________________________________________________________
RECORD RETRIEVAL FEES
The following record retrieval fees may be charged:
The requester is not charged for the first fifteen minutes of time. Charges for time are not to exceed the salary of the lowest paid full-time
employee who, in the discretion of the custodian of the records, has the necessary skill and training to perform the request.
City Hall Personnel Completing Request: _____________________________________ Date: ________________________
Comments: ___________________________________________________________________________________________
_____________________________________________________________________________________________________
CODES ENFORCEMENT CH RECEPTION BUSINESS TAX FIRE
COMMUNITY DEVELOPMENT ENGINEERING WATER FILTER POLICE
ALCOHOL LICENSING RECORDS CITY MANAGER UPKEEP
ASST. CITY MANAGER FINANCE WASTEWATER UTILITY BILLING
HUMAN RESOURCES RECREATION SANITATION _________________
Actual time of record preparation including research (varies)
(less 15 min.)
Hrs x $ =$
Actual time of copying (varies) Hrs x $ =$
$0.10 per page copy (8½ X 11)
$0.20 per page copy (11 x 17)
$2.00 per page for building plan
_____ Pages @ $0.10
_____ Pages @ $0.20
_____ Pages @ $2.00
=$
=$
=$
Postage =$
Other costs: =$
Video costs: Copies @$ .00 =$
Total actual costs:
=$
FOR OFFICE USE ONLY
_____________________
Date Received
_____________________
Time
_____________________
Staff Member Receiving
Request
click to sign
signature
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