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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 Records
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.
23. Date Response Due
    Date Response Due
24. Date Response Made
    Date Response Made
26. Copies Made
27. How Many
28. Cost
30. Time Taken to Fill Request (Hours)
32. Extension To
    Extension To
33. Extension Notice Sent
    Extension Notice Sent
    Attach copy.
34. Denied
    Denied
    Attach copy.
36. Signature of Employee Responding
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

* indicates a required field