Requestor's Name

Date

Address

Telephone Number

City

Zip Code

Secretary of State Employee Name, Title & Department to Receive FOI Request:

Department

Name

Title

RECORDS SOUGHT (Be Specific):

Requestor's Signature

The department will respond to a request for public records within seven (7) working days after its receipt. If your request is denied, you may file an appeal. Appeals should be addressed to the Assistant Secretary of State, 208 Capitol, Springfield, Illinois 62756.

(FOR DEPARTMENT USE ONLY)

Response:

Department  ______________________

Records Made Available          Date  _______________

Copies Made      Yes         No 

Request denied and why?     ______________________

How many? ______________________

Fee  ____________________________

Other (Attach Correspondence):

Department Comments (Use Reverse)

Date Request Received