State Form 1365 - Public Record Copy Request - State Of Indiana
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1LOCATION OF RECORD(S)
PUBLIC RECORD COPY REQUEST
Department / Agency
State Form 1365 (R3 / 11-99)
Approved by State Board of Accounts, 1999
Division / Institution
Section / Branch
IC 5-14-3
PLEASE TYPE OR PRINT FIRMLY - YOU ARE MAKING 2 COPIES.
RECORD(S) REQUESTED (identify by title, control number, date, description)
STANDARD SIZE (8 1/2" X 11" OR 8 1/2" X 14")
REQUEST MADE BY:
Name of requestor
Daytime telephone number
$
0.10
Uniform copy fee
No. of copies made
x
Address (if records are to be mailed):
TOTAL CHARGE
$
.
* Reasonable fee established by agency
NON-STANDARD SIZE
.
Agency fee *
$
No. of copies made
x
Date / time filled
Request filled by (name and title)
Date / time of request
.
TOTAL CHARGE
$
IF REQUEST IS NOT FILLED, STATE REASON (i.e., confidential by statute, etc.)
Signature
Title
Date
DISTRIBUTION: White - Requestor; Canary - Cashier
LOCATION OF RECORD(S)
PUBLIC RECORD COPY REQUEST
Department / Agency
State Form 1365 (R3 / 11-99)
Approved by State Board of Accounts, 1999
Division / Institution
Section / Branch
IC 5-14-3
PLEASE TYPE OR PRINT FIRMLY - YOU ARE MAKING 2 COPIES.
RECORD(S) REQUESTED (identify by title, control number, date, description)
STANDARD SIZE (8 1/2" X 11" OR 8 1/2" X 14")
REQUEST MADE BY:
Daytime telephone number
0.10
Name of requestor
$
Uniform copy fee
No. of copies made
x
Address (if records are to be mailed):
.
TOTAL CHARGE
$
* Reasonable fee established by agency
NON-STANDARD SIZE
.
Agency fee *
$
No. of copies made
x
Date / time filled
Request filled by (name and title)
Date / time of request
$
.
TOTAL CHARGE
IF REQUEST IS NOT FILLED, STATE REASON (i.e., confidential by statute, etc.)
Signature
Title
Date
DISTRIBUTION: White - Requestor; Canary - Cashier
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