State of New Jersey
Department of the Treasury
GOVERNMENT RECORDS REQUEST FORM
Important Notice
The reverse side of this form contains important information related to your rights concerning government records. Please read it carefully.
In addition, please note that you may complete and submit requests electronically on the Internet at www.nj.gov/opra
Requester Information
Please Print
Payment Information
First Name MI Last Name
Company
Mailing Address
City State Zip Email
Business Hours Telephone Extension
Fax
Preferred Delivery: Pick Up US Mail On Site Inspect Fax _____ Email _____
Check One: Under penalty of N.J.S.A. 2C:28-3, I certify that I _____HAVE / _____HAVE NOT been convicted of
any indictable offense under the laws of New Jersey, any other state, or the United States.
Signature
Date
I agree to pay for fees related to this
request no greater than
$
Select Payment Method
Cash
Check
Money Order
Fees: Letter Size @$0.05
Legal Size @$0.07
Extras: Extraordinary service fees
dependent upon request.
Record Request Information: To expedite the request, be as specific as possible in describing the records being requested.
Request Access to: Inspect Or Receive a Copy
STATE USE ONLY
Estimated Record Cost
Special Cost
Total Cost Estimated
Comments:
Denied
Approved-Records to be granted
in seven business days
Approved – Records will take
longer than seven business days
Tracking Information Final Cost
ID #
Total
Ready Date
Deposit
Date Mailed
or Picked Up
Balance Due
Total Pages
Balance Paid
Date Paid
Records Provided
Custodian Signature
Date
In accordance with Requesting Access to Government Records Under the New Jersey Open Public Records Act
(N.J.S.A. 47:1A-1 et seq.):
1. In order to request access to government records under OPRA, you must complete all the required portions of and date
this request form and deliver it in person during regular business hours, by mail, fax or electronically to the Treasury
Government Records Access Unit (GRAU). Your request is not considered filed until the GRAU has received the
completed request form. If you submit the request form to any other officer or employee of the Department of the
Treasury, that officer or employee does not have the authority to accept your request form on behalf of the Department
of the Treasury and you will be directed to the GRAU. Descriptions of the divisions and agencies of the Department of
the Treasury can be found at www.nj.gov/treasury/
2. Only requests submitted on this form to the Treasury GRAU will be considered official requests under the Open Public
Records Act. Deadlines, restrictions and remedies will not apply to requests unless submitted to the GRAU on this form.
3. The fees for duplication of a government record in printed form are listed on the front of this form. You will also be
required to pay any special charges, special service charges or other additional charges authorized by State law or
regulation. If estimated costs exceed the maximum amount you stated you were willing to pay, we will contact you for
authorization before proceeding. Payment shall be made by cash, check or money order payable to the State of New
Jersey.
4. If it is necessary for the records custodian to contact you concerning your request, identifying information, such as your
name, address and telephone number or an e-mail address is required. Where contact is not necessary, anonymous
requests are permitted; except that anonymous requests for personal information are not honored.
5. Anonymous requests, when permitted, require a deposit of 50% of estimated fees if we believe the costs of the requested
amount will exceed $15. You agree to pay the balance due upon delivery of the records.
6. The Department of the Treasury must deny access to a person who has been convicted of an indictable offense in New
Jersey, any other state, or the United States, and who is seeking government records containing personal information that
may pertain to the person’s victim or the victim’s family.
7. The Department of the Treasury must notify you that it grants or denies a request for access to government records
within seven business days after receiving the request, provided that the record is currently available and not in storage.
If the record requested is not currently available or is in storage, the Department of the Treasury will advise you within
seven business days when the record can be made available and the estimated cost. You may agree to extend the time the
Department of the Treasury has for making records available, or for reviewing your request.
8. You may be denied access to a government record if your request would substantially disrupt agency operation or the
Department of the Treasury is unable to reach a reasonable solution with you.
9. If the Department of the Treasury is unable to comply with your request for access to a government record, we will
indicate the reasons for denial on the request form and send you a signed and dated copy.
10. Except as otherwise provided by law or by agreement with the requester, if the Department of the Treasury fails to
respond to you within seven business days of receiving a request form, the failure to respond will be considered a denial
of your request.
11. If your request for access to a government record has been denied or unfilled within the time permitted by law, you have
a right to challenge the decision by the Department of the Treasury to deny access. At your option, you may either
institute a proceeding in the Superior Court of New Jersey or file a complaint in writing with the Government Records
Council (GRC). You may contact the GRC by toll-free telephone at 866-850-0511, by mail at PO Box 819, Trenton, NJ,
08625, by e-mail at grc@dca.state.nj.us, or at their web site at www.nj.gov/grc. The Council can also answer other
questions about the law.
12. Information provided on this form may be subject to disclosure under the Open Public Records Act.
Please submit form to:
The Department of the Treasury
Division of Administration – Government Records Access Unit
PO Box 215
Trenton, NJ 08625
Fax: 609-292-7247
Fo
r more information, contact the Department of the Treasury’s Government Records Access Unit at
(609) 633-1300 or mailto:AccessUnit.TreasuryGovernmentRecords@treas.nj.gov.