Request For Computer Data - New York City Department Of Finance

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New York City Department of Finance
REQUEST FOR COMPUTER DATA
TM
INSTRUCTIONS: Use this form to request computer data. Upon completion of Parts A, B and C, fax this
Department of Finance
form to the Department of Finance, Legal Affairs Division, at 718-488-2491.
PART A: APPLICANT INFORMATION
1. Name of
2. Company
Applicant: _______________________________________________________
Name: ____________________________________________
3. Company
Zip
Address:________________________________________________________ State: _______________________ Code:__________________
4. Type of
Business: _____________________________________________________________________________________________________________
5. Telephone
6. Fax
7. E-mail
Number: _____________________________
Number: ____________________________
Address: _____________________________
PART B: DATA REQUESTED
8. Describe the data you are requesting: ______________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
9. Indicate the purpose for which the data will be used:* __________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
q
q
q
10. Timeframe data is needed by: ___________________ 11. Preferred Media:
FTP
Flash Drive
CD/DVD
(CHECK ONE ONLY)
(IF SIZE PERMITS)
*The authority for requesting this information is based upon Section 87(2)(b) and 89(2)(b)(iii) of the Public Officers Law. These sections
permit us to protect personal privacy by withholding lists of names and addresses to be used for commercial or fund-raising purposes.
PART C: CERTIFICATION
I hereby affirm that the information provided on this request form is correct.
__________________________________________________
__________________________________
Signature
Date of request
DO NOT WRITE BELOW THIS LINE
Company No.:________________________________
Request No.: ____________________________
Date Received:____________________
Approved by Legal Affairs _________________________________
Disapproved by Legal Affairs __________________________________
Reason disapproved: ______________________________________________________________________________________________________
Reviewed by: _______________________________________
______________________________________
__________________________
Printed name
Signature
Date
Comments:______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Visit Finance at nyc.gov/finance
Request for Computer Data Rev. 08.10.2016

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