Government Records Request Form
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1
2State of New Jersey
Department of the Treasury
GOVERNMENT RECORDS REQUEST FORM
Important Notice
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
Payment Information
I agree to pay for fees related to this
request no greater than
First Name
MI
Last Name
$
Company
Select Payment Method
Mailing Address
Cash
City
State
Zip
Email
Check
Money Order
Business Hours Telephone
Extension
Fax
Fees:
Letter Size
@$0.05
Legal Size
@$0.07
Preferred Delivery:
Pick Up
US Mail
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.
Signature
Date
Extras:
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:
Inspect
Or
Receive a Copy
STATE USE ONLY
Tracking Information
Final Cost
Total
ID #
Comments:
Estimated Record Cost
Deposit
Ready Date
Date Mailed
Balance Due
Special Cost
or Picked Up
Balance Paid
Total Cost Estimated
Total Pages
Date Paid
Records Provided
Denied
Approved-Records to be granted
in seven business days
Approved – Records will take
longer than seven business days
Custodian Signature
Date
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Parent category: Financial