S:\FORMS\Administrative\Public Records Request adopted 12-11-17.rtf
Name: _______________________________________________________ Date: ______________________________
Address: ________________________________________________ Email: ___________________________________
Home Phone: ( )__________________ Business: ( )_____________________ Fax: (_____)_______________
Please check one of the following:
___ Arrange an opportunity to personally inspect the requested records
___ Have these records ___mailed or ___emailed
___ Pick them up from City Hall
Public Records/Information being requested (Please be specific, attach additional sheet if needed):
(1) ___________________________________________________________________________________________
(2) ___________________________________________________________________________________________
(3) ___________________________________________________________________________________________
Reason for Request: ______________________________________________________________________________
If you are requesting information about a specific parcel of land, you must provide the following information:
Street Address: ___________________________ Assessors Map #_______________________ Tax Lot #________
Requestor to Read and Sign upon Submitting Request
I understand that every person has a right to inspect any public record of a public body in this state, except as otherwise
expressly provided by ORS 192.501 to 192.505. Further, I understand that fees will be charged in accordance with
Exhibit “A” to Resolution No. 1231. I agree to pay any estimated fees in advance to reimburse the City for its actual cost
in making the records available. Such calculation may include staff time, costs for summarizing, compiling, or tailoring a
record to meet my request. Large documents may need to be taken to a commercial business for copying, in which case
the fee will reflect actual costs, plus staff time. I hereby request the City of Veneta produce the record(s) specified above.
__________________________________________ __________________________________
Signature Date
Date Request Received
Estimated Staff Time
Date Records Provided
Deposit Amount
Deposit Paid (Receipt #)
Staff Person
Balance Owing
Paid (Receipt #)
Refund Owing
Records provided or copies attached:
Public Records Request
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