Date of Request
Requester Contact Information
Name:
Organization:
Address:
City, State, Zip:
Phone:
E-mail:
Records Requested:
Check one: Paper copies Electronic copies Certified copies Inspection (in person)
Please be specific and include as much detail as possible regarding the records you are requesting.
To complete an estimate, the agency will need the following information:
I will pick up Please FedEx
Fed Ex billing number:
Please send USPS E-mail (if format allows)
Statement
I understand there may be a charge for copies of public records. I understand I will receive a written estimate for production of the
records indicated above if the estimated cost is expected to be over $25.00, which I will be required to pay in full prior to inspection or
reproduction. Materials will be held for 30 days.
Requester
Signature
Signature
Office Use Only
Date
__________________
Request received
Date
__________________
Attorney General’s Office notified
__________________
Receipt acknowledgement issued
__________________
Director’s Office notified
__________________
Request filled
__________________
Estimated completion
__________________
Estimate provided
__________________
Request denied in whole
__________________
Other:
Retain request form for 90 days following completing of request.
RDA 2009047
STATE OF NEVADA
Public Records Request
Deliver, Mail, or Fax to:
555 Wright Way, Carson City, NV 89711
Fax: (775) 684-4809
Attention: Public Records Officer
