State Form 49407 - Formal Complaint - 2001

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OFFICE OF THE PUBLIC ACCESS COUNSELOR
FOR OFFICE USE ONLY
FORMAL COMPLAINT
Date received (month, day, year)
State Form 49407 (R2 / 7-01)
Indiana Government Center South
Complaint number
Indianapolis, IN 46204
Telephone: (317) 233-9435 or 1 (800) 228-6013
Facsimile: (317) 233-3091
INSTRUCTIONS: This form is to be used only when filing complaints under Indiana Code 5-14-5. All information provided is disclosable under the Access to
Public Record Act. PLEASE TYPE OR PRINT.
COMPLAINANT INFORMATION
Name (last, first, middle initial)
Address (number and street)
State
City
ZIP code
E-mail address
Telephone number
Facsimile number
INFORMATION ABOUT PUBLIC AGENCY DENYING ACCESS
Name of public agency
Address (number and street)
State
City
ZIP code
E-mail address
Telephone number
Facsimile number
Name of Elected / Appointed Official or Presiding Officer responsible for the denial
COMPLAINT (Check All That Apply)
Open Door Law Violation
Public Records Access Violation
Executive Session
Denial of Access
Copy Fee
Notice
Other _______________________
Denial of Electronic Access
Other __________________________________________
IMPORTANT
Date denied access to public record:
Request for priority status [See Indiana Admin. Code (62 IAC 1-1-3)]
Date notified of denial of access to meeting:
Please describe denial of access to meeting or public records below. Attach additional sheets if necessary. (Required)
PLEASE ATTACH COPIES OF ANY WRITTEN DENIAL OR DOCUMENTATION CONCERNING DENIAL
Signature
Date (month, day, year)

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