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CITY OF COUNTRYSIDE

FREEDOM OF INFORMATION MEMORANDUM

REGARDING REQUEST FOR RECORD(S)

On the __________ day of ___________, 20 ____, at the hour of ______, the following individual(s) appeared in

person at the office of the City Clerk and asked to inspect the following records:

Request submitted by: _______ Email, _______ USPS, _______ FAX, _______ In Person

Individual making the request:____________________________________________________________________

Address (city, state, zip code):______________________________________________________________________

Day Telephone Number:______________________________ Email:_______________________________________

Fax: _________________

APPLICANT SIGNATURE:______________________________________________

Records sought to be inspected:__________________________________________________________________

______________________________________________________________________________________________

Do you want copies of the documents?

YES or NO

Do you want Electronic copies or paper copies? _________________________________________________

If you want Electronic copies, in what format? __________________________________________________

Is this request for a Commercial Purpose?

YES or NO

(It is a violation of the Freedom of Information Act for a person to knowingly obtain a public record for a commercial

purpose without disclosing that it is a commercial purpose, if requested to do so by the public body. 5 ILCS

140.3.1(c)).

Are you requesting a fee waiver?

Yes or NO

(If you are requesting that the public body waive any fees for copying the documents, you must attach a statement of

the purpose of the request, and whether the principal purpose of the request is to access or disseminate information

regarding the health, safety and welfare or legal rights of the general public. 5 ILCS 140/6(c)).

The above records were presented to such individual for inspection at _________ am/pm, on the _______ day of

_____________, 20 ___, except for: ________________________________________________________________

______________________________________________________________________________________________

The reason(s) for not providing the above records (or portion of records) was:

______________________________________________________________________________________________

Of records requested, copies of the records were provided to or made by the individual making request:

Date & Time of Memo: ______________________________Title of Employee: _______________________________

Signature of Employee: ________________________________ Witness: ___________________________________

i:/word/FOIA/2010 FOIA Request Form

Freedom Of Information Memorandum Regarding Request For Record(S) - City Of Countryside