**Note to Requester: Retain a copy of this request for your files. If you eventually need to file a Request for Review with the Public Access Counselor, you will need to submit a copy of your FOIA request. **
Name and Address of Public Body Receiving Request:____________________________________________________________________________________________________________________________________________
Date Requested: ________________________________________________________
Request Submitted By: _____E-mail _____U.S. Mail _____Fax _____In Person
Name of Requester: _____________________________________________________
Street Address: _________________________________________________________
City/State/CountyZip (required): ___________________________________________
Telephone(Optional): __________________ E-mail (Optional): ___________________
Records Requested: *Provide as much specific detail as possibleso the public body can identify the information that you are seeking. You may attach additional pages, if necessary.
Do you want copies of the documents? YES or NO
--Do you want Electronic Copies or Paper Copies? ________________________
--If you want Electronic Copies, in what format? __________________________
Is this request for a Commercial Purpose? YES or NO
(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. 5ILCS140.31(c))
Are you requesting a fee waiver? YES or NO
(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 principle purpose is to access or disseminate information regarding the health, safety, and welfare or legal rights of the general public. 5 ILCS140/6©).