Public Records Act Request Form Page 2
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2Fax to: Stephanie Leach, Statewide Records Coordinator at (916) 322-3470
INFORMATION RE RESPONSE TO PUBLIC RECORDS ACT REQUEST:
Responsible program or district office
Telephone #
Name
Name/telephone # of Local
Records Coordinator:
Date
Method
Date responsive letter sent/
Method of delivery (mail,
overnight, e-mail, fax)
Description of information
Disclosed (include #
Of documents)
If information withheld -
exemptions or privileges asserted
Describe information that was
withheld, if any
Date information disclosed
Amount of copy fee
Date Received
Date of receipt of PRA request/
How received
how request was received
(e.g., walk-in, letter)
Does any further action need to be
taken re this request?
Authorized Agent:
Knox Attorney Service, Inc./ Knox Services LLC.
PRA request log and tracking form
April 2006
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