Foia Request Form December 2015
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1C o u n t y o f F a i r f a x , V i r g i n i a
To protect and enrich the quality of life for the people, neighborhoods and diverse communities
FOIA Request Form
Pursuant to Code of Virginia 2.2-3700, the Virginia Freedom of Information Act (FOIA) citizens have the right to access public
records with specific exemptions. Please fill out this form to ensure your request is fulfilled accurately. More information about FOIA
is posted online at PLEASE PRINT THE REQUESTED INFORMATION BELOW.
Name
__________________________________________________________________________________________________
Phone
Fax:
: _________________________________________
_________________________________________________
Email
Date:
: __________________________________________
________________________________________________
Company/Organization
: ________________________________________________________________________________
Requestor’s Address
: ___________________________________________________________________________________
Requested Properties, if applicable
(Records can be searched only by full postal address or Tax Map ID):__________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Information Requested
: _________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Check one:
Print Requested Records
Email Requested Records (when possible)
Save Requested Records on a Computer Disk
Charges
VFOIA [Va. Code Ann. Section 2.2-3704 (F) (Supp. 2009)] permits reasonable charges not to exceed the actual cost incurred
in accessing, duplicating, supplying, or searching for the requested records. You may request an advanced estimate of the
charges. If the estimated charges exceed $200, payment will be required prior to processing your FOIA request. An itemized
FOIA expense form is available upon request.
Costs
1.
Cost for staff time to assemble requested information and for special computer runs is calculated by staff time
expended for accessing, duplicating, supplying or searching for the requested records not to exceed actual cost.
2.
$.10 per page when records exceed ten pages.
3.
$5 per plat.
4.
Computer Disk, not to exceed the actual cost of the disk(s).
____________________________________________________
________________________________
Signature
Date
This section for Health Department staff only:
FOIA request taken by phone, form filled out by ____________________________________ Charges explained to caller? YES
NO
Dec. 2015
To request this information in an alternate format, call the
Fairfax County Health Department
Health Department at 703-246-2411; TTY 711
10777 Main Street
Suite 203
Fairfax, VA 22030
703-246-2411 FAX: 703-653-9463
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