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2. Description of Record Requested (be specific with dates or range of records being request):*
4. Requester and Record Identification*
6. First Name
7. Last Name
9. Address1
11. City
12. State
13. Zip
15. Telephone Number (Include Area Code)*
17. E-Mail Address*
19. Signature of Requester**
21. If the cost of responding to a request is estimated to exceed $10.00, the person requesting the records will be provided with an estimate of costs, which the person will need to agree to pay prior to the copies being made. If the cost of responding to a request exceeds $50.00, the person requesting the records will need to pay the estimated costs prior to the copies being made.
23. *This information is not required, but will be used to provide a response, or in the event clarification is needed and for billing purposes.
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25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit Submit and Print

* indicates a required field