Public Records Request Form A
Individual Request
City of Cookeville Police Department
10 E. Broad Street, PO Box 849
Cookeville, TN 38503
931-520-5326
The Tennessee Public Records Act (TPRA) grants Tennessee citizens the right to access open public records that exist at
the time of the request. The TPRA does not require records custodians to compile information or create or recreate
records that do not exist.
To: Administrative Services Division Commander, 10 E. Broad Street, PO Box 849, Cookeville, TN 38503
From: _______________________________________ ____________________________________
Requestor’s Name Phone
_______________________________________ ____________________________________
Street Address, City, Zip Code E-mail Address
Is the requestor a Tennessee citizen? Yes No
Is the requestor a victim in the record requested? Yes No
Request: Inspection (The TPRA does not permit fees or require a written request for inspection only.)
Copy/Duplicate
If costs for copies are assessed, the requestor has a right to receive an estimate. Do you wish to waive
your right to an estimate and agree to pay copying and duplication costs in an amount not to exceed
$_________________? If so, initial here: ______________.
Delivery preference: On-Site Pick-Up USPS First-Class Mail
Electronic Other: ________________________
Records Requested:
Provide a detailed description of the record(s) requested, including: (1) type of record; (2) timeframe or dates for
the records sought; and (3) subject matter or key words related to the records. Under the TPRA, record requests
must be sufficiently detailed to enable a governmental entity to identify the specific records sought. As such, your
record request must provide enough detail to enable the records custodian responding to the request to identify
the specific records you are seeking.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
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I acknowledge that response to my request may take up to seven business days. Initial here: ________.
__________________________________ ____________ ________________________________ ____________
Signature of Requestor Date Signature of Receiving Employee Date Received
Directions for Completing the Public Records Request Form A
From: The name of the person making the request.
Phone: Phone number through which the requestor can be contacted.
Street Address: Address including city of residence and ZIP code of the requestor where records can be sent.
E-mail Address: E-mail address through which the requestor can be contacted or records sent.
Citizenship: Proof provided of Tennessee residency (picture identification issued by the state, etc.)
Victim Status: Each victim of the record requested is provided a minimally redacted paper copy of the record
without charge.
Request:
Inspection of a properly redacted public record may be made without charge in the presence of a record
custodian at the time and place scheduled by the record custodian or departmental PRRC. The requestor
making an inspection of a paper record may capture images of the record with their own device without charge.
If the requestor wants the record custodian to provide paper copies of a record, the requestor can indicate the
maximum amount they are willing to pay for simple requests without an itemized list of applicable fees. If the
requestor does not provide a maximum charge amount, the request cannot be completed until an itemized fee
summary is approved by the departmental PRRC. Likewise, an itemized fee summary approved by the
departmental PRRC will be required for requests requiring significant research and redaction and requests for
video/audio recordings before the request is completed.
Delivery Preference: The requestor must indicate their preferred method of receiving the record requested.
Records Requested: The requestor must provide as much descriptive information as possible about the record in
question to facilitate fulfilling the request.
Acknowledgement of Seven Day Notification Period: The requestor must initial their acknowledgement of the
seven-day limit to respond to the request as specified in the TPRA.
Requestor Signature and Date: The requestor must sign their request and provide the date the request was made
to a record custodian.
Employee Signature and Date: The employee receiving the request must sign the form and provide the date the
request was received.
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