Government Agency Request

For staff of federal, state, county and municipal agencies requesting records or information for official purposes. Attach the official request letter, subpoena or court order where one exists.

Please print clearly in black or blue ink. Fields marked * are required.

1Requesting agency

Agency name *

Level of government *

Federal State County Municipal Other

Requesting officer or staff member *

Direct phone number *

Government email address * — Must be an official .gov address.

2The request

Your case or reference number *

Records or information needed, and the purpose *

I certify that the information on this form is true and accurate to the best of my knowledge.

Signature Date