Request For Public Records Form - Dupage County Health Department
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1R
F
P
R
EQUEST
OR
UBLIC
ECORDS
U
I
F
I
A
NDER THE
LLINOIS
REEDOM OF
NFORMATION
CT
(please print)
Telephone Number:
Requestor Name:
(if applicable)
Area Code (
)
Company Name:
Mailing Address:
Fax Number: (
)
Mailing City, State, Zip:
Email Address:
Description of Requested Record(s): (Please also see Environmental Health Services records listing as a reference).
Indicate if you wish to inspect records, receive copies of records or both inspect and obtain copies of records.
Inspection
Copy
Inspection and Copy
Please indicate how you prefer to receive copies of records (be sure to complete the contact information above)
Email
Regular U.S. Postal Mail
FAX
th
Record inspection takes place at: 111 North County Farm Road, Room 419, 4
Floor, Wheaton, Illinois.
If applicable, copying fees will be quoted once records have been collected. You may request a full or partial fee
waiver under limited circumstances.
By my signature, I, the undersigned, acknowledge that the Freedom of Information Act is not intended:
To violate individual privacy;
•
•
For the purpose of furthering a commercial enterprise;
•
To disrupt the duly undertaken work of the public body.
I understand the Department has five (5) business days to respond following the date the request is received. I also understand
the Department may request an additional five (5) business days, if necessary, to fill my request. I further understand that if it is
determined that some or all of the requested materials may not be disclosed, I will receive a written denial including the reason
for denial and explaining my right to appeal. I also understand that I may be charged with costs associated with this request.
_______________________________________________
____________________
Signature of Requestor
Date
P
:
LEASE SUBMIT THIS COMPLETED REQUEST TO
FOR OFFICE USE ONLY
Penny Chanez, FOIA Officer
Date Request Received: __________________________
DuPage County Health Department
Date Response Due: ____________________________
111 North County Farm Road
Wheaton, Illinois 60187
Copying fee received. Date: ______________________
Telephone Number: (630) 682-7400 extension 7660
Fax Number: (630) 221-7661
Amount: $ ________
Cash
Check # _______
Email:
H
D
R
R
P
R
EALTH
EPARTMENT
ESPONSE TO
EQUEST FOR
UBLIC
ECORDS
The documents will be made available upon payment of copying costs in the amount of $ __________.
The documents are available for inspection at the address referenced above.
Other, explain: __________________________________________________________________________
Revised October 2011
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