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2. Requester Information:
4. First Name*
5. Last Name*
7. Address
8. City
9. State
10. Zip
12. Daytime Phone Number:
13. Email Address:*
14. Date
    Date

    Date
16. Status:

    1. Not applicable because the record is public.
    2. I am the subject of the record.
    3. I am the parent or legal guardian of a minor who is the subject of the record.

    1. I am the provider of the information.
    2. I have a power of attorney or notarized release from the subject of the record or provider of the information.
    3. I have a legislative subpoena or court order.
18. If selected power of attorney/release of information, please upload it here:
20. Signature (Please type name):
22. Description of Record(s) Requested (Must be described specifically):
24. Record Request Forms are Public Documents
28. FOR OFFICE USE ONLY:
    Date Received: ____________________________
    Time Received: ____________________________ AM or PM

    
    CLASSIFICATION OF RECORD REQUESTED:
    ( ) Public
    ( ) Private
    ( ) Protected
    ( ) Controlled

    
    CITY RESPONSE TO RECORD REQUEST:
    ( ) Released on: __________________
    ( ) Denied (See Attached) __________________
    ( ) Request for Extraordinary Circumstances (See Attached).
    

    
    FEE CHARGED:__________________
    
    SIGNATURE OF RECORD PROVIDER ____________________________________

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

    This field is not part of the form submission.

32. Submit Submit and Print

* indicates a required field