St. Charles Police Department Foia Request Form Page 2

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In order to help to determine status to assess fees, select:
An individual seeking information for personal use
Affiliated with an educational or noncommercial institution, and this request is made
for a scholarly purpose
Affiliated with a private corporation and seeking information for use in the
company's business
A representative of the news media and this request is made part of news gathering
and not for commercial use
Enter media name:
_____________________________________________________________________________
_____________________________________________________________________________
Select type of Media:
Newspaper
Magazine
Television Station
Other
Enter maximum amount you are willing to pay: $
_____________________________________________________________________________
_____________________________________________________________________________
Explanation for a request for a waiver of fees:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Additional Comments:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
This form cannot be used for Privacy Act requests for information about a third party.

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