Records Request Form Page 2
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2Records Request Form (page 2 of 2)
(Exhibit B)
Fees (for office use only)
Copy Charges:
_______B/W pages $1.00 for the first page + $0.25 for add’l pages =
$__________
_______Color pages$1.00 for the first page + $0.34 for add’l pages =
$__________
oversize pages (to be determined case by case) =
$__________
Fax Charges -- 10 page maximum:
________ pages x $0.50/page =
$__________
Documents Scanned to Email:
________ pages x $0.10/page =
$__________
$__________
Electronic Files Burned to CD, $5 per CD
$__________
Postage Charges -- Certified Mail, Regular Mail:
actual cost =
$__________
Other (please specify): _____________________________________
actual cost =
$__________
Other (please specify): _____________________________________
actual cost =
$__________
Staff Services: (first 15 minutes free per request) specify redacting time, search time,
supervision of records examination, copying time, etc.
_________________________________________________________________________
Name of Employee(s) Performing These Services: ________________________________
(Department Staff, IT Staff, Finance Department Staff, etc.)
_______ hours (¼ hour increments) x $________ employee hourly rate =
$__________
_______ hours (¼ hour increments) x $________ employee hourly rate =
$__________
TOTAL OF ALL FEES
$__________
less deposit received (if any)
-$__________
balance
owed at pickup
to be refunded
$__________
Deposit Received on: _________________________________ (date and time)
in the amount of $__________________ by _____________________________ (employee)
Final Payment Received on __________________ by ____________________________ (employee)
Dept.__________________ Revenue Code________________ Date Taken to Treasurer________________
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