Name
of Agency
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City
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INSTRUCTIONS:
Requestor
should fill out the request portion (the top half) and sign the Requestor's
Signature block. Send copies 1 and 2 to the Agency. Keep the 3rd copy for
references. Send no money at this time. Unless notified otherwise the
Agency's response for APPROVED, DENIED or DEFERRED will be sent back within 7
working days after receipt of the form.
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Address
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Requestor's
Name (or business name if applicable)
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Date
of Request
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Phone
Number
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Street
Address
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CERTIFICATION
REQUESTED YES NO
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Requestor's
Signature
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City
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State
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Zip
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DESCRIPTION
OF RECORDS REQUESTED:
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REQUESTING
COPIES
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TO INSPECT RECORDS
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AGENCY
RESPONSE (REQUESTOR DOES NOT FILL IN BELOW THIS LINE)
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APPROVED
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The
documents requested are enclosed.
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The
documents will be made available upon payment of copying costs ............................................... $_____________
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You
may inspect the record at ___________________________________________________________________________
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on
the date of ______________________.
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DENIED
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The
request creates an undue burden on the public body in accordance with Section
3(f) of the Freedom of Information Act, and we are unable to negotiate a more
reasonable request.
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The
materials requested are exempt under Section 7____ of the Freedom of
Information Act for the following reasons:
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INDIVIDUAL(S)
THAT DETERMINED REQUEST TO BE DENIED
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RIGHT TO APPEAL
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If
desired, submit the attached APPEAL form (No. 2) along with copies of the
original REQUEST and reasons for appeal to:
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DEFERRED
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Request delayed,
for the following reasons (in accordance with 3(d) of the DOIA):
You
will be notified by the date of ___________________________ as to action
taken on your request.
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The
information required by this form is MANDATORY in order to comply with P.A.
83-1013. Failure to so provide may result in this form not being processed.
This form is approved by the Form
Management
Center.
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FOIA
Officer
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Date
of Reply
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