Foia Request Form (Village Of Coal Valley/coal Valley Police Department)
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Village of Coal Valley/Coal Valley Police Department
Upon Receipt
Official Request For Public Records
Under The Illinois Freedom Of Information Act
Requestor Information:
NAME: __________________________________________________________
ADDRESS: _______________________________________________________
CITY: _________________________ STATE: ________ ZIP: ______________
TELEPHONE(S): __________________________________________________
Please describe below the public records you are requesting. To expedite the search, please be as specific as possible. If
known, please also include date(s) of requested records.
________________________________________________________________________________________________________
Date & Time of Incident or Case Report # if known (Police)______________________________________________________
The above records are requested for:
Inspection
Copy
Certification
I would like to receive my copies by:
Mail
Pick Up
Email
Fax______________
(Standard black and white photocopies will be provided at no charge for the first fifty (50) pages. Requestor will be charged
15¢ per page beyond fifty. Certification is $1 per document.)
Is this request being made for a commercial purpose?
Yes
No
NOTE: “Commercial purpose” means the use of any part of a public record or any information derived from a public record in
any form for sale, resale, or solicitation or advertisement for sales or services. It is a violation of the Freedom of Information
Act to knowingly obtain information for a commercial purpose without disclosing that intent to the Village.
The Village of Coal Valley/Coal Valley Police Department will respond to this request within five (5) business days. If
responding to the request requires an extension of time of up to five (5) additional business days, the requestor will be sent
notice in writing. Commercial requests will receive a response within twenty-one (21) business days.
_______________________________
______________________________
(Requestor Signature)
(Date)
Mail/Deliver to: Allen May/FOIA Officer Village
Sandra Standefer, FOIA Officer, Village / Police
Penny Woods/FOIA Officer Village
Amber Dennis, FOIA Officer Village / Police
st
900 1
Street – P.O. Box 105
Chief Mark Poulos FOIA Officer- Police
Coal Valley, IL 61240
Lt. Jack Chick, FOIA Officer - Police
st
900 1
Street/P.O. Box 121, Coal Valley, IL 61240
Phone: 309-799-3604 Facsimile: 309-799-3651
Phone (309) 799-5416 Facsimile: (309) 799-3651
__________________________________________________________________________________________
FOR OFFICIAL USE ONLY
Request Received By: ________________________________ Completed By:_______________________Date: _________________
Document(s) made available on: _______________
Inspection
Pickup
U.S. Mail
Email
Fees Collected: $____________/Copies $_______________ /Certification $____________ /Other
COMPLETE BELOW IF ACCESS TO ANY RECORD(S) IS DENIED
Reason for Denial (cite FOIA exemption): ____________________________________________________________________
Name/Title of Officer Issuing Denial: ___________________________________________________
Date of Response: _______________________ Attach copy of all written responses for file.
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