Name of Requestor: | ||||||
Address: | Phone: | |||||
Date of Request: | Time of Request: | |||||
Nature of Request: | ||||||
1. Index Reference. . . . | ||||||
2. If not identifiable by reference to the index, then describe the document(s) in detail. . . . | ||||||
. . . . | ||||||
. . . . | ||||||
Signature. . . . | ||||||
For Office Use Only: | ||||||
(1) | Record Withheld In Part □ | |||||
Request Granted □ | Record Withheld □ | |||||
(2) | If withheld, name the exemption contained in section 31, chapter 1, Laws of 1973, which authorizes the withholding of the record or part of record: Subsection (1) ( ). | |||||
(3) | If withheld, briefly explain how the exemption applies to the record withheld. | |||||
(4) | If request granted, time . . . . ., day . . . . .. | |||||