Ct-0445 - Inspection/duplication Of Records Request Form Page 2
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Costs continued:
c. Estimate of labor costs to produce the copy (for time exceeding 1 hour): _____________________
Labor at $__________ /hour for _____________ hour(s).
Labor at $__________ /hour for _____________ hour(s).
Labor at $__________ /hour for _____________ hour(s).
d. Programming cost to extract information requested:___________________________
e. Method of delivery and cost:____________
Estimated
On-site pick-up
U.S. Postal Service
Other: ______________________
f. Estimate of total cost to produce request: ________________________
g. Estimate provided to requestor:
in person
by U.S.P.S.
by phone
Other:____________
8. Payment:
a. Form of payment:
Cash
Check
Other________________________________________
b. Amount of payment: _______________________________________________________________
c. Date of payment: __________________________________________________________________
d. Actual cost (and adjustment if prepaid):_________________________________________________
9. _________________________________
_______________________________
Signature of Requestor
Date Records Requested
10. _________________________________
_______________________________
Signature of Records Custodian
Date of Receipt of Request
Delivery/Retrieval of Records
11. _____________________________________
___________________________________
Signature of Requestor
Date Records Retrieved
12. ______________________________________
____________________________________
Signature of Records Custodian
Date Records Retrieved/Delivered
Or
_____________________________________
Date Records Inspected by the Requestor
Inspection/Duplication of Records Request
Tenn. Code Ann. § 10-7-503(a)(7)(A)
Form #CT-0445
Revised 12/10
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