State Of New Jersey Department Of Transportation/ Transportation Trust Fund Authority Government Records Request Form

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AD-274 ((10/2012)
State of New Jersey
Department of Transportation/
Transportation Trust Fund Authority
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
Requester Information – Please Print
Payment Information
I agree to pay for fees related to this
request no greater than
First Name
MI
Last Name
$
Company
Select Payment Method
Cash
Mailing Address
Check
City
State
Zip
E-mail
Money Order
Business Hours Telephone:
Area Code
Number
Extension
Fees:
Letter size pages $0.05 each
Fax
Area Code
Number
Legal size pages $0.07 each
Other materials
Preferred Delivery:
PICK UP
US MAIL
ON SITE INSPECT
E-MAIL
(CD,DVD, etc.) –
actual cost of
Check One: Under penalty of N.J.S.A. 2C:28-3, I certify that I _____HAVE / _____HAVE NOT been convicted of
material
any indictable offense under the laws of New Jersey, any other state, or the United States.
Delivery: Delivery / postage fees
additional depending upon
delivery type.
Signature
Date
Extras: Extraordinary service fees
dependent upon request.
Record Request Information: To expedite the request, be as specific as possible in describing the records being requested.
STATE USE ONLY
Tracking Information
Final Cost
Total
ID #
Comments:
Estimated Record Cost
Deposit
Ready Date
Date Mailed
Balance Due
Special Cost
or Picked Up
Balance Paid
Total Cost Estimated
Total Pages
Date Paid
Records Provided
Denied
Approved-Records to be granted
in seven business days
Approved – Records will take
longer than seven business days
Custodian Signature
Date

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