State of New Jersey
Department of the Treasury
GOVERNMENT RECORDS REQUEST FORM
The reverse side of this form contains important information related to your rights concerning government records. Please read it carefully.
In addition, please note that you may complete and submit requests electronically on the Internet at
Requester Information – Please Print
I agree to pay for fees related to this
request no greater than
Select Payment Method
Business Hours Telephone
On Site Inspect
Fax _____ Email _____
Check One: Under penalty of N.J.S.A. 2C:28-3, I certify that I _____HAVE / _____HAVE NOT been convicted of
any indictable offense under the laws of New Jersey, any other state, or the United States.
Extraordinary service fees
dependent upon request.
Record Request Information: To expedite the request, be as specific as possible in describing the records being requested.
Request Access to:
Receive a Copy
STATE USE ONLY
Estimated Record Cost
or Picked Up
Total Cost Estimated
Approved-Records to be granted
in seven business days
Approved – Records will take
longer than seven business days