appendix a request for public records
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)	Request Granted □	Record Withheld □	Record Withheld In Part □
(2)	If withheld, name the exemption contained in § 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 . . . . . .