Open Public Records Act Request Form - Township Of Saddle Brook
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4TOWNSHIP OF SADDLE BROOK
OPEN PUBLIC RECORDS ACT REQUEST FORM
93 MARKET STREET, SADDLE BROOK, NJ 07663
201-587-2909 FAX: 201-587-2908
Peter Lo Dico, Township Clerk
Important Notice
The last page of this form contains important information related to your rights concerning government records. Please read it carefully.
Requestor Information – Please Print
Payment Information
Maximum Authorization Cost $
First Name
MI
Last Name
Select Payment Method
E-mail Address
Cash
Check
Money Order
Mailing Address
Fees:
Letter size pages - $0.05
City
State
Zip
per page
Legal size pages - $0.07
per page
Telephone
FAX
Other materials (CD, DVD,
Pick
On-Site
etc) – actual
Preferred Delivery:
Up
US Mail
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.
AGENCY USE ONLY
AGENCY USE ONLY
AGENCY USE ONLY
Tracking Information
Final Cost
Disposition Notes
Custodian: If any part of request cannot be
Est. Document Cost
Total
Tracking #
delivered in seven business days,
Deposit
Rec’d Date
detail reasons here.
Est. Delivery Cost
Balance Due
Ready Date
Est. Extras Cost
Balance Paid
Total Pages
Total Est. Cost
Records Provided
Deposit Amount
Estimated Balance
In Progress
-
Open
Deposit Date
Denied
-
Closed
Filled
-
Closed
Partial
-
Closed
Custodian Signature
Date
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