State Of New Jersey - Government Records Request Form printable pdf download

State Of New Jersey - Government Records Request Form

State of New Jersey

Department of Human Services

GOVERNMENT RECORDS REQUEST FORM

Important Notice

The reverse side of this form contains important information related to your rights concerning government records. Please read it carefully.

In addition, please note that you may complete and submit requests electronically on the Internet at

Requestor Information – Please Print

Payment Information

Maximum Authorization Cost $________

First Name ___________________________

MI _______

Last Name_____________________

Company_______________________________________

Select Payment Method

Mailing Address__________________________________

City_________________________________

Check

State________________________________

Money Order

Zip________________________________________

Email______________________________________

Fees:

Pages 1-10 @$0.75 per page

Business Hours Telephone:

Pages 11-20@$0.50 per page

Area Code __________

Pages 21 -@$0.25 per page

Number____________________

Delivery:

Extension_____________

Delivery / postage fees additional

depending upon delivery type.

Preferred Delivery:

Extras:

Pick Up

Extraordinary service fees

US Mail

dependent upon request.

On Site Inspect

Circle One: Under penalty of N.J.S.A. 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.

SIGNATURE_________________________________________

DATE_______________________

State Of New Jersey - Government Records Request Form