STANDARD RIGHT-TO-KNOW REQUEST FORM
DATE REQUESTED: _________________
REQUEST SUBMITTED BY:
□ E-MAIL □ U.S. MAIL □ FAX □ IN-PERSON
REQUEST SUBMITTED TO (Agency name & address):__________________________________________
________________________________________________________________________________________
NAME OF REQUESTER :___________________________________________________________________
STREET ADDRESS:_______________________________________________________________________
CITY/STATE/COUNTY/ZIP(Required): ________________________________________________________
TELEPHONE (Optional):_____________________ EMAIL (optional):_____________________________
RECORDS REQUESTED: *
Provide as much specific detail as possible so the agency can identify the information.
Please use additional sheets if necessary
DO YOU WANT COPIES?
□ YES □ NO
DO YOU WANT TO INSPECT THE RECORDS?
□ YES □ NO
DO YOU WANT CERTIFIED COPIES OF RECORDS?
□ YES □ NO
DO YOU WANT TO BE NOTIFIED IN ADVANCE IF THE COST EXCEEDS $100?
□ YES □ NO
** PLEASE NOTE: RETAIN A COPY OF THIS REQUEST FOR YOUR FILES **
** IT IS A REQUIRED DOCUMENT IF YOU WOULD NEED TO FILE AN APPEAL **
____________________________________________________________________________
FOR AGENCY USE ONLY
OPEN-RECORDS OFFICER:
□ I have provided notice to appropriate third parties and given them an opportunity to object to this request
DATE RECEIVED BY THE AGENCY:
AGENCY FIVE (5) BUSINESS DAY RESPONSE DUE:
**Public bodies may fill anonymous verbal or written requests. If the requestor wishes to pursue the relief and remedies
provided for in this Act, the request must be in writing. (Section 702.) Written requests need not include an explanation
why information is sought or the intended use of the information unless otherwise required by law. (Section 703.)
