Open Public Records Act Request Form - Township Of Barnegat
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4TOWNSHIP OF BARNEGAT
OPEN PUBLIC RECORDS ACT REQUEST FORM
900 WEST BAY AVENUE, BARNEGAT NJ 08005
Forward Request to:
Barnegat Township Municipal Clerk, Custodian of Records
609-698-0080 (Phone) 609-698-7980 (Fax)
clerk@barnegat.net
Requestor Information – Please Print
Payment Information
Maximum Authorization Cost $
First Name
Last Name
Select Payment Method
E-mail Address
Cash
Check
Money Order
Mailing Address
Fees:
Letter size pages - $0.05 per
City
State
ZIP
page
Legal size pages - $0.07 per
page
Telephone
FAX
Other materials (CD, DVD,
Pick
US Mail ___
On-Site
etc) – actual cost of material
Preferred Delivery:
Up
Fee may apply
Inspect
Fax _______ E-mail _______
Delivery: Delivery / postage fees
additional depending upon
If you are requesting records containing personal information, please circle one: Under penalty of N.J.S.A.
delivery type.
2C:28-3, I certify that I HAVE / HAVE NOT been convicted of any indictable offense under the laws of New
Jersey, any other state, or the United States.
Extras:
Special service charge
dependent upon request.
Signature
Date
Record Request Information: Please be as specific as possible in describing the records being requested. Also, please note that your
preferred method of delivery will only be accommodated if the custodian has the technological means and the integrity of the records will not
be jeopardized by such method of delivery.
Request Address ____________________________________________________________________ Block________________ Lot_________________
Survey_______
Resale C/O_______
Rental CO_______ Tax Info_______ Permits________ Other ___________
Signature of Township Custodian ____________________________________________________
Date____________________
Forward to Following Department
:
CONSTRUCTION ______
CLERK ______
COURT ______
TAX COLLECTOR _____
P / Z
______
POLICE ______
TAX ASSESSOR ______
FINANCE _____
CODE
______
REQUEST COMPLETED BY:_________________________________ NO. OF PAGES___________
FORM OF REPLY: FAX_________
EMAIL_________CALLED FOR PICK UP__________ MAILED___________
Signature of Requestor upon receipt of documents:____________________________________
Date______________
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