State Of New Jersey - Government Records Request Form Page 2

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Requesting Access to Government Records Under the New Jersey Open Public Records Act (N.J.S.A. 47:1A-1 et seq.)
Record Request Information: To expedite the request, be as specific as possible in describing the records being requested. Also, please
include the type of access requested (copying or inspection), and if data, the medium requested.
STATE USE ONLY
STATE USE ONLY
STATE USE ONLY
Disposition Notes
Tracking Information
Est. Document Cost____________________
Custodian: If any part of request cannot be
Final Cost
delivered in seven business days,
detail reasons here.
Tracking #______________________________
Est. Delivery Cost______________________
Total__________________________________
In Progress
-
Open
Est. Extras Cost_______________________
Rec’d Date_____________________________
Denied
Deposit________________________________
-
Total Est. Cost________________________
Closed
Ready Date____________________________
Filled
-
Deposit Amount_______________________
Balance Due___________________________
Closed
Partial
Total Pages____________________________
Estimated Balance_____________________
-
Closed
Balance Paid___________________________
Deposit Date_________________________
Records Provided
Custodian Signature__________________________________________
Date______________________

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