Fillable Request Form Page 1 CITY OF ROCKFORD REQUEST (CITY OF ROCKFORD)

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Request Form Page 1 CITY OF ROCKFORD REQUEST (CITY OF ROCKFORD)

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Request Form Page 1
City of Rockford, Rockford, IL Request for Public Records-Official Request Form
CITY OF ROCKFORD
REQUEST FOR PUBLIC RECORDS
OFFICIAL REQUEST FORM
INSTRUCTIONS AND INFORMATION
a. In Section 1, describe the public records that you wish to inspect or to have copied or certified.
Please be precise about what records you seek. You may use a separate sheet if necessary.
Indicate whether you request only to inspect the public records or whether you also request to
have the public records copied and certified by checking the appropriate spaces.
b. By submitting this Request Form, you are agreeing to pay to the City, in advance of receiving
copies of any public records, the copying fees set forth in Section 2.
The fees set forth in Section 2 may be waived or reduced by the Freedom of Information
Officer on determination and proof that the purpose of your request is primarily to benefit the
general public and that you will receive no significant personal or commercial benefit from
your request. If you wish to be considered for a fee waiver or reduction, you must complete the
statement set forth in Subsection 2.B.
c. In Section 3, indicate the purposes for which you are requesting the public records identified in
Section 1. You must provide the information in Section 3.
d. The City will not mail copies of public records except upon satisfactory proof that it would be
unduly burdensome for you to inspect, receive via e-mail, or pick up the copies and then only
upon advance payment of the actual cost of postage. You must complete the statement set forth
in Section 4.
e. You must provide the information requested in Section 5.
f. You must sign the statement set forth in Section 6.
The City will disclose the public records requested on this Request Form within 21 Business Days after the receipt of this Request
Form for all requests made for commercial purposes, and within five Business Days for all other requests, unless the applicable
response period is extended as provided by law or the request is denied. All extensions and denials will be in writing and will
state the reasons therefore. The Requestor may seek review of a denial by the Public Access Counselor of the Office of the
Illinois Attorney General. Judicial review is available under Section 11 of the Illinois Freedom of Information Act, 5 ILCS 140/1
et seq. For more detailed information, please consult the City of Rockford Policy for Implementation of the Illinois Freedom of
Information Act, which is available from the Freedom of Information Liaison Officer.
Request Form Page 2
City of Rockford, Rockford, IL Request for Public Records-Official Request Form
1. Request for Records
I request the following public records of the City:
Records requested (field will continue to grow as you type. Enter your complete request
in detail):
Inspect Copy
Request Form Page 3
City of Rockford, Rockford, IL Request for Public Records-Official Request Form
2. Agreement to Pay Fees (check/complete A. or B. below)
A. Unless I have requested and received a waiver under Subsection B of this Section,
I will pay the following fees for the public records copied at my request:
1. Copies – 8½ x 11 or 8½ x 14, Black and White
First 50 pages Free
Additional pages $.15 per page
2. Other types of records @ actual cost of reproduction $
3. Postage @ actual cost $
I agree that I will pay the actual charges that the City incurs in connection with
the copying services, and the fees stated in items 1 through 3. I further agree that
the fees stated in items 1 through 3 above will not apply if the fee for the
requested records is otherwise fixed by statute. If the requested records are
produced on an electronic medium, I agree to pay the actual cost of purchasing
the medium.
B. I request a waiver of the fees set forth in Subsection A, and in support of my
request I hereby certify that I will gain no significant personal or commercial
benefit from the public records herein requested and that my principal purpose in
making this request is to benefit the general public by disseminating information
concerning the health, safety, welfare, or legal rights of the general public in the
following specific manner:
3. Purpose of Request
Please check Yes or No
for each of the following:
Yes
A. I am requesting the public records identified in Section 1
No
to use the records, or the information derived therein, for sale,
resale, solicitation, or advertisement for sales or services.
B. I am, or represent, news media or a non-profit, scientific
or academic organization.
C. The principal purpose of this Request for Public Records is to
access and disseminate information concerning news and current
or passing events.
Request Form Page 4
City of Rockford, Rockford, IL Request for Public Records-Official Request Form
D. The principal purpose of this Request for Public Records is for
articles of opinion or features of interest to the public.
E. The principal purpose of this Request for Public Records
is academic, scientific, or public research or education.
Pursuant to Section 3.1(c) of the Freedom of Information Act, it is a violation of
the Act for a person to knowingly obtain a public record for a commercial purpose
without disclosing that it is for a commercial purpose.
4. Method of Delivery
E-Mail Fax Mail In Person
5. Requestor
A. Name of Requestor:
B. Address for Responses, Decisions, and Communications:
C. Contact Information of Requestor:
Work:
Home:
C
ell:
Fax:
E-mail:
6. Signature of Requestor
By entering my name below, I acknowledge and represent that I have reviewed and
understand the City of Rockford Policy for Implementation of the Illinois Freedom of
Information Act, and under penalties as provided by law pursuant to §1-109 of the
Illinois Code of Civil Procedure, that all of the information provided in
support of this request is true and accurate.
Request Form Page 5
City of Rockford, Rockford, IL Request for Public Records-Official Request Form
/s/Check here to approve the use of your digital signature
___________________________
Please print your name Signature of Requestor
'DWH
“*Note: If you are sending in this form electronically, you do not need to sign your name with a pen. However, you will need to check
the below /s/ digital signature box, or you can click the "Signature of Requestor" box to digitally sign this form if you're familiar with
signing Adobe PDF's.”
Date will be entered automatically...
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Request Form Page 1 CITY OF ROCKFORD REQUEST (CITY OF ROCKFORD)

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Completed 15 July 2020

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