Request for Records
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Thursday, 06 December 2012 09:02

REQUEST FOR RECORDS IN ACCORDANCE

WITH THE FREEDOM OF INFORMATION ACT

 

I AM REQUESTING TO:                 COPY           INSPECT          CERTIFY

(CHECK APPROPRIATE BOX)…the following public records:

 

INFORMATION REQUESTED: (Please be specific):

______________________________________________________________________________

 

Requested By:

Name:________________________________________________________________________

Address:______________________________________________________________________

City/State/Zip:_________________________________________________________________

Phone:_______________________________________________________________________

E-Mail (optional)___________________________________ Fax (optional)_________________

 

Will this material be used for commercial purposes? Yes___________   No_____________

 

The first 50 pages for black and white, letter or legal sized copies are free.  After the first 50

pages, the charge for black and white, letter or legal sized copies will be $ .15 per copy (each

side).  Certification of documents is an additional $1.00 (per certified document).

 

A response to your request will be made within five (5) business days of the receipt of this

request.  Please return with a copy of this request on ______________________________.

 

INFORMATION RECEIVED:

Date:______________________________   By:_______________________________________

  (Print Name)

                                                                                      _________________________________

                                                                                      Signature

______________________________________________________________________________

Number of Photocopies:_________________           Total Cost:___________________________

Photocopying Fees:_____________________           Paid in Full:__________________________

Certified Fees:_________________________           Form of Payment:_____________________

______________________________________________________________________________

For Office Use Only

Request Taken By:___________________________  Date: _______________ Time:________

Department:____________________________Title__________________________________

A response to your request for _________________________records has been extended for

5 working days until______________for the following reason(s):_________________________

Denial Sent By:______________________________ 

Date: _______________ Time:________ for the following reason:________________________

Authorized by:  Director ______________________________________________________

 

CHICAGO RIDGE PARK DISTRICT

10736 S. Lombard

Chicago Ridge, IL  60415

Revised July, 2011

 


Chicago Ridge Park District