Open Public Records Act Request Form - Township Of Mansfield
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4TOWNSHIP OF MANSFIELD
OPEN PUBLIC RECORDS ACT REQUEST FORM
100 Port Murray Road, Port Murray, NJ 07865
908-689-6151 phone, 908-689-2840 fax
dhrebenak@mansfieldtownship-nj.gov
Dena Hrebenak, Records Custodian
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
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