Government Records Request Form - City Of Perth Amboy
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2CITY OF PERTH AMBOY
260 High St. Perth Amboy, NJ 08861
Phone (732) 826-0290 Fax (732) 826-6623
GOVERNMENT RECORDS REQUEST FORM
Important Notice
The attached form contains important information related to your rights concerning government records. Please read it carefully.
Requestor Information – Please Print
Payment Information
First Name
MI
Last Name
Maximum Authorization Cost $
Company
Select Payment Method
Cash
Check
Money Order
Mailing Address
Fees :
City
State
Zip
Email
$0.10 Per Page
Business Hours Telephone:
Area Code
Number
Extension
Property & 200’ Owners
Preferred Delivery:
Pick Up
US Mail
On Site Inspect
List $10.00
Circle One:
Under penalty of N.J.S.A. 2C: 28-3, I certify that: I HAVE / HAVE NOT been convicted of any
Video Recordings: $1.00
indictable offense under the laws of New Jersey, any other state, or the United States.
Audio Recordings: $1.00
Signature
Date
Delivery:
Delivery / postage fees
additional depending upon
delivery type.
RECORD REQUEST INFORMATION: TO EXPEDITE THE REQUEST, BE AS SPECIFIC AS
POSSIBLE IN DESCRIBING THE RECORDS BEING REQUESTED. ALSO, PLEASE INCLUDE THE
Extras:
Extraordinary service fees
TYPE OF ACCESS REQUESTED (COPYING OR INSPECTION), AND IF DATA, THE MEDIUM
dependent upon request.
REQUESTED.
Document Requested: (Please circle one: COPY or INSPECTION)
Minutes ______________________________________________________________________________________________________________
Ordinance/Resolution __________________________________________________________________________________________________
Property Owners List: Address ____________________________________________________ Block _______________ Lot ______________
Certified 200’ Property Owner’s List: Address ________________________________________ Block _______________ Lot ______________
Municipal Lien Search: Address ____________________________________________________Block _______________ Lot ______________
Other: ________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
AGENCY USE ONLY
AGENCY USE ONLY
AGENCY USE ONLY
Tracking Information
Final Cost
Disposition Notes
Due Date:
______________
Total Pages
_____________
Cash/Check:
______________
Total Fee
_____________
Check #
______________
Deposit
_____________
Amount
______________
Receipt #
_____________
Sent to : ______________________________________
___________________________________________________
___________________________________________________
Records provided : _____________________________
___________________________________________________________
_____________________________________
___________________
Custodian Signature
Date
Modified 4/20/11
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