Village of Chenequa
Public Records Request Form
In an effort to fulfill your request in the timeliest manner, please be as specific as possible in your request.
Also, please fill in all information requested. You will be contacted when our request is ready for review
or pick up in compliance with Wisconsin State Statute Sec. 19.35(4). If no phone number is provided,
response will be left for pick up for a period of 7 days.
Date of request: ________________________________________________________________
Requester Name: _______________________________________________________________
Street Address: _________________________________________________________________
City, State, Zip: ________________________________________________________________
Phone #: ______________________________________________________________________
Description of record(s) requested:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please note: A request for access to a public record may not be refused “because the person making the request is
unwilling to be identified or to the state the purpose of the request.” [19.35(l)(i), Wis Stats.] You are being asked to
provide the information called for on a voluntary basis. Thank you.
…………………………………………………………………………………………………………………………..
TO BE COMPLETED BY VILLAGE CLERK OR DEPUTY CLERK
Department receiving request: ____________________________________________
Date & time request received: ____________________________________________
Action taken on request:
[ ] Approved
[ ] Denied
[ ] Approved in part/Denied in part
Attach copy of any statement denying access to, a copy of, or information contained in any
public record covered by this request.
Signature of Custodian approving release: ___________________________________________
Fee Due: _________ Paid: YES NO
Date & Time Record released: __________________ Released By: _______________________
