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2. Requester's Name*
3. Date
   Date
5. Street Address*
6. E-Mail Address
8. City*
9. State*
10. Zip Code*
12. Telephone Number*
14. Title
15. Agency/Company Name (If Applicable)
17. Department*
    -- Select One --Township RecordsAssessor RecordsCommunity Mental Health Board
19. Records Sought*
    Be as specific as possible.
21. Is this for Commercial Purposes?*

    1. Yes
    2. No

    Commercial purpose means the use of any part of a public record or records or information derived from public records, in any form, for sale, resale, solicitation or advertisement for sales or services.  Requests made for commercial use allow for 21 business days for a response.  

23. Signature of Requester
25. The agency will respond to or deny a request for public records within 5 business days after its receipt.
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31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

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