FOIA Request Form
Requester's
Name: _________________________________________________________________________________________________________________________
Address: __________________________________________________________________________________________________________________________________
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Phone Number (optional): __________________________________________________________________________________________________________________
Fax Number (optional): ____________________________________________________________________________________________________________________
E-Mail (optional): __________________________________________________________________________________________________________________________
Subject: __________________________________________________________________________________________________________________________________
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__________________________________________________________________________________________________________________________________________
In order to help to determine status to assess fees, select:
Enter media name: _______________________________________________________________________________________________________________________
Select type of Media:
Newspaper
Magazine
Television Station
Other
Purpose: ________________________________________________________________________________________________________________________________
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________________________________________________________________________________________________________________________________________
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Enter maximum amount you are willing to pay: $ ___________________________________________________________________________________________
Explanation
for a request for a waiver of fees: _____________________________________________________________________________________________
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_______________________________________________________________________________________________________________________________________
Additional
Comments: __________________________________________________________________________________________________________________
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This
form cannot be used for Privacy Act requests or requests for
information about a third party.
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