Foia Request Form - Kankakee County Health Department
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1Kankakee County
FOIA Request Form
Name of Department Submitted to:_____________________________________________________
Date Requested: ____________________________________________________________________
Request Submitted By:
E-mail
U.S. Mail
Fax
In Person
Name of Requester:__________________________________________________________________
Street Address: _____________________________________________________________________
City/State/County Zip (required): _______________________________________________________
Telephone (Optional): E-mail (Optional): _________________________________________________
Fax (Optional): _____________________________________________________________________
Records Requested:
*Provide as much specific detail as possible so the public body can identify the information that
.
you are seeking. You may attach additional pages, if necessary
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Do you want copies of the documents?
YES
NO
--Do you want Electronic Copies or Paper Copies? ____________________________________
--If you want Electronic Copies, in what format? _____________________________________
Is this request for a Commercial Purpose?
YES
NO
(It is a violation of the Freedom of Information Act for a person to knowingly obtain a public record for a commercial
purpose without disclosing that it is for a commercial purpose, if requested to do so by the public body. 5 ILCS
140.3.1(c)).
Are you requesting a fee waiver?
YES
NO
(If you are requesting that the public body waive any fees for copying the documents, you must attach a statement of
the purpose of the request, and whether the principal purpose of the request is to access or disseminate information
regarding the health, safety and welfare or legal rights of the general public. 5 ILCS 140/6(c)).
• Note to requester: Retain a copy of this request for your files. If you eventually need to file a
Request for Review with the Public Access Counselor, you will need to submit a copy of your
FOIA request.
Signature: _____________________________________________ Date:_____________________
Submit by Email
Print Form
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