Records Request Form

Please note: state law does not require any agency to create any record to fulfill a request. GRAMA applies only to existing records. In some cases, you may need to provide a Social Security Number or other personal identifier to retrieve records. In the case of a request for medical records, the agency may require you to complete a HIPAA release. DO NOT include your Social Security Number on this form. The agency will provide a separate method for you to provide that number if it is needed.

Name of requester

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

From whom are you requesting the records? (Name of county agency/office holding the records and name of contact person if known.)

Description of records requested. (Be as specific as possible; type of records, subject, year or dates wanted, etc.)

Check all that apply:

*** I understand that I will be responsible for copy costs. I authorize costs of up to $__________. I understand that prepayment of copies over $50.00 may be required and that I will be contacted if estimated costs are greater than the above specified amount. (Please enter you're authorized amount here)

If the requested records are not Public, please explain why you believe you are entitled to access.

If you selected "Other" above, please explain here.

File Upload

Signature

Records Request Form - GRAMA