Request for Information Form

2. Date Requested
   Date Requested

3. Public Request No.

5. Request Submitted By

   1. Email
   2. U.S. Mail

   1. Fax
   2. In-Person

7. Name of Requestor (Optional)

   Attach business card if applicable.

9. Property Owner

   1. Yes
   2. No

11. Street Address

13. City/State/County*

15. Telephone

16. Fax

17. Email

19. Description of Requested Information

    Provide as much specific detail as possible so the Township can identify the information. If additional sheets are required they must be stapled and the total pages included below.

21. Specify Year(s) for Material Being Requested (If Applicable)

23. Do you want to inspect the records?

    1. Yes
    2. No

24. Do you want copies?

    1. Yes
    2. No

26. If Yes, Instructions for Delivery of Requested Information

28. If Yes, Instructions for Delivery of Requested Information

    1. Pick Up
    2. Fax
    3. Mail

    1. Email
    2. Disk/CD (Provided)
    3. Other

29. Explain

31. Do you want certified copies of records?

    1. Yes
    2. No

35. Date Request for Information Received
    Date Request for Information Received

36. Open Records Officer

38. 5 Business Days from Date of Receipt of Request

40. Extension Letter Mailed

    1. Yes
    2. No

41. Approval of Extension beyond 30 days

    1. Yes
    2. No

43. Date Extension Letter Provides for Fulfilling Request
    Date Extension Letter Provides for Fulfilling Request

45. Date Request Fulfilled
    Date Request Fulfilled

46. Open Records Officer

48. Request Fulfilled By:

50. Picked Up

51. Faxed

52. Mailed

53. Emailed

55. Other

57. List of Documents Required

Leave This Blank:


58. Submit

* indicates a required field