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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*
13. Title
15. Department*
    -- Select One --Township RecordsAssessor RecordsCommunity Mental Health Board
17. Records Sought*
    Be as specific as possible.
19. Signature of Requester
21. The agency will respond to or deny a request for public records within 5 business days after its receipt.
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28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field