Open Public Records Act Information Request Form - Hudson Regional Health Commission
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3HUDSON REGIONAL HEALTH COMMISSION
595 COUNTY AVENUE, BUILDING 1
SECAUCUS, NJ 07094
TEL. (201) 223-1133 FAX (201) 223 0122
John P. Sarnas, President
Carrie Nawrocki, Director
Open Public Records Act Information Request
Important Notice
Important information related to your rights concerning government records and the address to which this form
must be submitted are attached. Please read this form and the attachment carefully. You must complete both pages
of this form. Only one property may be included on each request.
Requestor Information – Please Print
Payment Information
Max. Cost Authorization
$____________
First Name _______________________ MI ______ Last Name ______________
Select Payment Method
Company__________________________________________________________
Cash___ Check __ Money Order__
Copying Charges (per/page)
Mailing Address____________________________________________________
Letter Size
$0.05 each
Legal Size
$0.07 each
City______________State______Zip_________Email_____________________
Delivery / Postage Fees:
Business Hours Telephone: Area Code____Number______________Ext.______
Actual postage unless charged to
receivers account.
Circle One: Under penalty of N.J.S.A. 2C:28-3, I certify that I HAVE /
Other Charges:
HAVE NOT been convicted of any indictable offense under the laws of New
Additional service fees may apply to
Jersey, any other state or the United States.
requests for records in non-standard
formats or reports that must be
compiled.
Signature____________________________________ Date_________________
Tracking Information
Disposition Notes
Records Provided:
Number of Pages: ____________
Tracking #_________
Copy Charges: _______________
Date received by custodian: _________________
Shipping charges: _____________
Date requestor
informed of disposition: ____________________
Other Charges: _______________
Status
Total due: ___________________
Filled
In Progress
________________________________
Denied
Custodian Signature
Date
Hudson Regional Health Commission Use Only
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