1. Requester Information

Your Full Legal Name

Mailing Address

Phone Number

Email Address

Date Issued

2. Recipient Agency

Agency Name

Agency FOIA Office Address

Subject Line (Internal Reference)

3. Specific Records Requested

Describe the records you are seeking in detail. (Be as specific as possible to avoid delays.)

4. Fee Waiver & Format

Fee Category Commercial Use (Highest fees) Representative of the News Media Educational/Scientific Institution All Other Requesters (Lower fees)

Willingness to Pay Fees (USD - $)

Fee Waiver/Reduction Justification (Required if asking for reduced/zero fee)

Preferred Format