Public Records Request Form C
City of Cookeville Police Department
10 E. Broad Street, PO Box 849
Cookeville, TN 38503
Business Name: ____________________________________________________________
Phone Number: ____________________________________________________________
FAX: ______________________________ Email: _______________________________
Full name of employee(s) authorized to submit requests:
Email will be the primary form of communication. The fee schedule shown below will apply:
$0.15 per page for letter and legal size black and white copies.
$0.50 per page for letter and legal size color copies.
$5.00 for each compact disc containing digital data (e.g., still pictures or video).
Labor when research or redaction time exceeds one hour.
The actual costs assessed by an outside vendor if such a vendor is needed to provide the
research or redaction services necessary to provide the record requested.
Payment can be made by cash or check payable to the City of Cookeville. The check can be sent to the
address shown above.
I give permission for the Cookeville Police Department to send me a monthly invoice to be paid within
15 days of receipt for reports that I request. Initial ___________
This request will be honored as promptly as possible. However, I acknowledge that my request may be
delayed for up to seven business days. Initial ___________
__________________________________ __________________________________ ___________________
Signature of Requestor & Date Signature of Employee Receiving Request Date Received