2. Date
   Date
3. Public Request Number
5. Name
6. Address
8. City / State / County
9. Phone
11. Fax
12. Email
14. Description of Requested Information
    Provide as much specific detail as possible so the township can identify the information.
16. Do you want to inspect the record?

    1. Yes
    2. No
17. Do you want copies?

    1. Yes
    2. No
18. Do you want certified copies of records?

    1. Yes
    2. No
20. Public bodies must fill anonymous requests. If the requestor wishes to pursue the relief and remedies provided for in this Act, the request must be in writing. (Section 702.). Written requests need not include an explanation why information is sought or the intended use of the information unless otherwise required by law. (Section 703.). Requests are subject to the fees established by the Township as allowed by the Act.
22. Request Date
    Request Date
23. Open Record Officer
24. 5 Days After Request
    5 Days After Request
26. Extension Letter Mailed?

    1. Yes

    1. No
27. Approval of extension beyond 30 days?

    1. Yes

    1. No
29. Date Extension Letter Provides for Fulfilling Request
30. Date Request Fulfilled
    Date Request Fulfilled
31. Open Records Officer
33. Request fulfilled by:

    1. In Person
    2. Fax

    1. Mail

    1. Email

    1. Other
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field