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Request Form
Date:_______________________________
Official or Agency:___________________________________________________________
(name and address)
___________________________________________________________________
(Telephone, fax and e-mail if available)
Person Requesting Records:
___________________________________________________________________
(name and address)
___________________________________________________________________
(telephone, fax and e-mail if available)
Records Requested (be specific and attach additional sheets if necessary):
___________________________________________________________________
___________________________________________________________________
____________________________________________________________
____________________________________________________________
I would like a copy of the records (check here):__________
- Standard copy fee for City-County government: $0.04 per page
- Standard copy fee for state government: $0.10 per page
- Certain records may have other fees (such as police reports and court records)
Please write or call me to advise me of the copy fee prior to mailing or faxing (check here):________
I would like to inspect the records during normal business hours at the agency and do not wish to obtain a copy at this time (no fee to inspect). Please write or call me to arrange: (check here):______
If my request is denied, under law an official or agency is required to respond in writing and state the statutory exception authorizing the withholding of all or part of the public record and the name and title or position of the person responsible for the denial
________________________________ ______________________________
(Signature) (Date – Month, Day, Year)
Return completed form to:
Lauren Toppen, Public Access Counselor
1601 City-County Building
200 E. Washington St.
Indianapolis, IN 46204
Phone: (317) 327-4055
Fax: (317) 327-3968
Email: PAC@indygov.org
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