Foia Request Form - Town Of Hamilton, Va
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FREEDOM OF INFORMATION ACT (FOIA)
REQUEST FORM
Name: _________________________________________________________________
Mailing Address: ________________________________________________________
________________________________________________________
Telephone Number: (H) _______________________ (W) _______________________
Email Address: __________________________________________________________
Documents Requested:
1) ____________________________________________________ # of copies _______
2)_____________________________________________________ # of copies _______
□
□
□
Delivery preference:
Postal Mail
Email
Pick-up
(Please note: Duplication, search and mailing fees will be charged. If the total is
$100.00 or greater you will be notified and given an opportunity to narrow your request.
Each request carries a $5 minimum research charge.
Signature: _________________________________________ Date: _______________
Clerk’s Use Only
Date Request Received ________________
Date Request Fulfilled ________________
Documents Exempted _____________________ Extension Needed ________________
Number of Copies
_____ x $ 0.06 (8.5x11”) =
_______
General Staff Time in Hours:
_____ x $ 20.00
=
_______
Specialized Staff Time in Hours:
_____ x $ 30.00
=
_______
Audio Media:
_____ x $ 1.00 (CD)
=
_______
Postage:
_______
Date Payment Received _______________
Total Paid =
_______
Notes___________________________________________________________________
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Parent category: Business