Request For Non-Police Records Form printable pdf download

CITY OF DETROIT

Michigan Freedom of Information Act (FOIA) Request for

NON-POLICE RECORDS

Please note that failure to complete certain fields on this form may result in a denial of your request.

Today’s date: _______________________________________________________________________

Individual making this request: ________________________________________________________

Street Address: _____________________________________________________________________

City/State/Zip: ______________________________________________________________________

Telephone number: ___________________________

Fax number: __________________________

Your client or insured (optional ): ______________________________________________________

Description of the record: ____________________________________________________________

__________________________________________________________________________________

Date and time or time period, if applicable: ______________________________________________

Identify City department or agency: ___________________________________________________

10. Any other information that will assist the department/agency in locating the requested record:

___________________________________________________________________________________

Signature: ___________________________________________________________

NOTE: 1) Failure to complete this form may result in a denial of your request.

2) For Buildings, Safety Engineering and Environmental Department record, please identify the address.

3) For contract or RFP/RFQ, please identify contract number or RFP/RFQ number and a description.

4) If the requested record pertains to an individual other than the requestor, a notarized authorization to

release the record may be required from the person who is the subject of the request.

5) If the request is too broad, depending on the description of your request, we may deny your request;

or request that you submit a deposit payment, prior to searching for the requested record.

6) Medical record requests (e.g., EMS run sheets or billings) must comply with HIPAA and the

Michigan Medical Records Access Act.

HAND-DELIVER OR MAIL THIS REQUEST TO:

City of Detroit FOIA Coordinator

City of Detroit Law Department

Coleman A. Young Municipal Center

2 Woodward Avenue, Suite 500

Detroit, Michigan 48226-3437

Request For Non-Police Records Form