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2. Name of Requester (Individual Submitting the Request):
4. Request is Made on Behalf of (Self, Name of Business or Organization):
6. Requester Phone Number:
7. Requester Fax Number:
8. Requester Email Address:
10. Specific Description of Records Requested:
12. Request is Made:

    (Check One or More)

    1. For commercial purpose*
    2. To inspect the above described records (requester will be notified when records are available for inspection and a time and place will be mutually agreed upon)
    3. For copies of the above described records
    4. To pick up the copies of the above described records (requester will be notified when records are ready)
    5. For the above described records to be provided in electronic format (CD Rom) when available
    6. To have copies of the above described records mailed (postage charges apply)
    7. To have the above described records sent by facsimile transmission to the number specified above
    8. To have the above described records sent by electronic mail to email address specified above
    9. For the above described records to be certified
14. *It is a violation of the Freedom of Information Act for a person to knowingly obtain a public record for a commercial purpose without disclosing that it is for a commercial purpose, if requested to do so by the public body. 5ILCS 140.3.1 ©
16. Waiver of Fees:

    1. Are you requesting for a fee waiver?

    If you are requesting that the public body waive any fees for copying the documents, you must attach a statement of the purpose of the request, and whether the principal purpose of the request is to access or disseminate information regarding the health, safety and welfare of legal rights of the general public. 5ILCA 140/6 ©
18. Signature of Requester:
19. Date:
23. OFFICE USE ONLY
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit Submit and Print

* indicates a required field