FRANCIS TOWN

UTAH GOVERNMENT RECORDS REQUEST FORM

 

TO:         ___________________________________________________________________________

                (Name of government office holding the records and/or name of agency contact person)

                Address of government office:  ___________________________________________________

                ___________________________________________________________________________

 

Description of records sought (records must be described with reasonable specificity):  _______________

__________________________________________________________________________________

 

___         I would like to inspect (view) the records.

 

___         I would like to receive a copy of the records.  I understand that I may be responsible for fees

                associated with copying charges or research charges as permitted by UCA 63-2-203.  I authorize

                costs of up to $________.

 

___         UCA 63-2-203 (4)  encourages agencies to fulfill a records request without charge.  Based on

                UCA 63-2-203 (4), I am requesting a waiver of copy costs because:

 

                ___         releasing the record primarily benefits the public rather than a person.  Please explain:

                                ____________________________________________________________________

                ___         I am the subject of the record.

                ___         I am the authorized representative of the subject of the record.

                ___         My legal rights are directly affected by the record and I am impoverished.  (Please

                                attach information supporting your request for a waiver of the fees.)

 

If the requested records are not public, please explain why you believe you are entitled to access.

 

                ___         I am the subject of the record.

                ___         I am the person who provided the information.

                ___         I am authorized to have access by the subject of the record or by the person who

                                submitted the information.  Documentation required by UCA 63-2-202, is attached.

                ___         Other.  Please explain:  _________________________________________________

                                ___________________________________________________________________

 

___         I am requesting expedited response as permitted by UCA 63-2-202 (3)(b).  (please attach infor-

                mation that shows your status as a member of the media and a statement that the records are

                required for a story for broadcast or publication; or other information that demonstrates that

                you are entitled to expedited response.)

 

Requester's Name:  __________________________________________________________________

Mailing Address:  ___________________________________________________________________

 

Daytime telephone number:  ______________________         Date  _____________________________

Signature:  __________________________________________________________________________

If records are filed by Social Security Number, please provide that number:  ________________________