Free 49407.pdf - Indiana

OFFICE OF THE PUBLIC ACCESS COUNSELOR FORMAL COMPLAINT
State Form 49407 (R2 / 7-01)

FOR OFFICE USE ONLY
Date received (month, day, year)

Indiana Government Center South Indianapolis, IN 46204 Telephone: (317) 233-9435 or 1 (800) 228-6013 Facsimile: (317) 233-3091

Complaint number

INSTRUCTIONS: This form is to be used only when filing complaints under Indiana Code 5-14-5. All information provided is disclosable under the Access to Public Record Act. PLEASE TYPE OR PRINT. COMPLAINANT INFORMATION
Name (last, first, middle initial)

Address (number and street)

City Facsimile number

State E-mail address

ZIP code

Telephone number

INFORMATION ABOUT PUBLIC AGENCY DENYING ACCESS
Name of public agency

Address (number and street)

City Facsimile number

State E-mail address

ZIP code

Telephone number

Name of Elected / Appointed Official or Presiding Officer responsible for the denial

COMPLAINT (Check All That Apply) Open Door Law Violation Executive Session Notice Other _______________________ IMPORTANT
Date denied access to public record: Date notified of denial of access to meeting:

Public Records Access Violation Denial of Access Copy Fee Denial of Electronic Access Other __________________________________________ Request for priority status [See Indiana Admin. Code (62 IAC 1-1-3)]

Please describe denial of access to meeting or public records below. Attach additional sheets if necessary. (Required)

PLEASE ATTACH COPIES OF ANY WRITTEN DENIAL OR DOCUMENTATION CONCERNING DENIAL Signature Date (month, day, year)