Request for Public Records (Written Request)

Date (required)

First Name (required)

Last Name (required)

Organization (If Applicable) or N/A (required)

Address (required)

Phone Number (required)

Email (required)

Pursuant to my rights under the California Public Records Act (Government Code Section 6250 et seq.), I, ask to (inspect/obtain a copy of) the following, which I understand to be held by your agency: (required)

I agree

(Describe the record as precisely as possible, including the designation of any forms or reports with titles, the date or dates if relevant, the author and addressee if the item is a letter or memo, etc. If the record is referred to in another document or published report and it will help to attach a copy of that reference, do so.) (required)

I ask that you notify me of any duplication costs exceeding (Indicate amount in box) before you duplicate the records so that I may decide which records I want copied. (required)

I ask for a determination on this request within 10 days of your receipt of it, and an even prompter reply if you can make that determination without having to review the record[s] in question. If I can provide any clarification that will help expedite your attention to my request, please contact me at the information I provided. (required)

I agree to all of the above

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