Ct-0445 - Inspection/duplication Of Records Request Form
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INSPECTION/DUPLICATION OF RECORDS REQUEST
Requestor Instructions: To make a request for copies of public records fill in sections 1-5, and sign and date section 9 at
the time the request is made. Requestors who are retrieving the requested records from the office of the records custodian in
person should not sign and date section 11 until the records are received. Requestors who are having the records emailed or
mailed to him/her are not required to sign and date section 11 of the form.
Custodian Instructions: For requests to inspect, the records custodian is to fill in sections 1-6,8, and sign and date section
10 at the time the request is made. Section 12 should not be signed and dated until the requestor inspects the records. For
requests for copies or duplicates, the records custodian is to fill in sections 6-8 and sign and date section 10 at the time the
request is made. Section 12 should not be signed and dated until the records are retrieved by or delivered to the requestor.
Note: Tenn. Code Ann. § 10-7-503(a)(7)(A) provides that unless another provision in law specifically requires a written request, a
request to inspect public records may not be required to be in writing nor can a fee be assessed for inspection of records.
(FRONT)
1. Name of requestor: _______________________________________________________________________
(Print or Type; Initials of requestor are required for copy requests)
2. (If required) Form of identification provided:
Photo ID issued by governmental entity including requestor’s address
Other: _______________________________________________________________________
3. Requestor’s address and contact information: __________________________________________________
__________________________________________________________________________________________
4. Request for:
inspection/access
copy/duplicate [previously inspected on _______
or
(date)
inspection waived]
5. Record(s) requested:
a. Type of record:
Minutes
Annual Report
Annual Financial Statements
Budget
Employee file
Other
b. Detailed Description of the record(s) including relevant date(s) and subject matter:
__________________________________________________________________________________________
__________________________________________________________________________________________
6. Request submitted to: ____________________________________________________________________
(Name of Governmental Entity, Office or Agency)
a. Employee receiving request:_________________________________________________________
(Print or Type and Initial)
b. Date and time request received:_______________________________________________________
c. Response:
Same day
Other _____________________________________________________
7. Costs (if assessed):
a. Number of pages to be copied: _____________
Estimated
b. Cost
(1) per page letter or legal sized:
$____(justification required if more than $0.15) per black and
white
$_____(justification required if more than $0.50) per color;
(2) per page other sized or other medium__________________:
$_____(justification required)
Inspection/Duplication of Records Request
Tenn. Code Ann. § 10-7-503(a)(7)(A)
Form #CT-0445
Revised 12/10
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