Free 01365.PDF - Indiana

PUBLIC RECORD COPY REQUEST
State Form 1365 (R3 / 11-99) Approved by State Board of Accounts, 1999 IC 5-14-3

LOCATION OF RECORD(S)
Department / Agency

Division / Institution

Section / Branch

PLEASE TYPE OR PRINT FIRMLY - YOU ARE MAKING 2 COPIES. RECORD(S) REQUESTED (identify by title, control number, date, description)

REQUEST MADE BY:
Name of requestor Daytime telephone number

STANDARD SIZE (8 1/2" X 11" OR 8 1/2" X 14")

Uniform copy fee $ No. of copies made x TOTAL CHARGE $

0.10 .

Address (if records are to be mailed):

* Reasonable fee established by agency
NON-STANDARD SIZE

Agency fee * $ No. of copies made x
Date / time of request Date / time filled Request filled by (name and title)

. .

TOTAL CHARGE
Signature Title

$

IF REQUEST IS NOT FILLED, STATE REASON (i.e., confidential by statute, etc.)

Date

DISTRIBUTION: White - Requestor; Canary - Cashier

PUBLIC RECORD COPY REQUEST
State Form 1365 (R3 / 11-99) Approved by State Board of Accounts, 1999 IC 5-14-3

LOCATION OF RECORD(S)
Department / Agency

Division / Institution

Section / Branch

PLEASE TYPE OR PRINT FIRMLY - YOU ARE MAKING 2 COPIES. RECORD(S) REQUESTED (identify by title, control number, date, description)

REQUEST MADE BY:
Name of requestor Daytime telephone number

STANDARD SIZE (8 1/2" X 11" OR 8 1/2" X 14")

Uniform copy fee $ No. of copies made x TOTAL CHARGE $

0.10 .

Address (if records are to be mailed):

* Reasonable fee established by agency
NON-STANDARD SIZE

Agency fee * $ No. of copies made x
Date / time of request Date / time filled Request filled by (name and title)

. .

TOTAL CHARGE
Signature Title

$

IF REQUEST IS NOT FILLED, STATE REASON (i.e., confidential by statute, etc.)

Date

DISTRIBUTION: White - Requestor; Canary - Cashier