Open Records - Guide To Hawaii'S Uniform Information Practices Act - Office Of Information Practices - 2015 Page 47
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69REQUEST TO ACCESS A GOVERNMENT RECORD
DATE:
____________________________
TO:
________________________________________________________________________
FROM:
________________________________________________________________________________
Name or Alias
________________________________________________________________________________
Contact Information
________________________________________________________________________________
Although you are not required to provide any personal information, you should provide enough information to
allow the agency to contact you about this request. The processing of this request may be stopped if the agency
is unable to contact you. Therefore, please provide any information that will allow the agency to contact you
(name or alias, telephone or fax number, mailing address, e-mail address, etc.).
I WOULD LIKE THE FOLLOWING GOVERNMENT RECORD
:
Describe the government record as specifically as possible so that it can be located. Try to provide a record
name, subject matter, date, location, purpose, or names of persons to whom the record refers, or other
information that could help the agency identify the record.
A complete and accurate description of the
government record you request will prevent delays in locating the record. Attach a second page if needed.
I WOULD LIKE:
(please check one or more of the options below)
To inspect the government record.
A copy of the government record: (Please check one of the options below.) See the back of this page
for information about fees that you may be required to pay for agency services to process your record
request. Note: Copying and transmission charges may also apply to certain options.
Pick up at agency (date and time): ____________________________________________
Mail
Fax (toll free and only if available)
Other, if available (please specify): ____________________________________________
If the agency maintains the records in a form other than paper, please advise in which
format you would prefer to have the record.
Electronic
Audio
Other (please specify):_____________________
Check this box if you are attaching a request for waiver of fees in the public interest
(see waiver information on back).
SEE BACK FOR IMPORTANT INFORMATION
(rev. 9/12/01)
OIP 1
A
A
PPENDIX
O
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- J
2015
47
PEN
ECORDS
UNE
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