PUBLIC RECORD COPY REQUEST
State Form 1365 (R3 / 11-99) Approved by State Board of Accounts, 1999 IC 5-14-3
LOCATION OF RECORD(S)
Department / Agency
Division / Institution
Section / Branch
PLEASE TYPE OR PRINT FIRMLY - YOU ARE MAKING 2 COPIES. RECORD(S) REQUESTED (identify by title, control number, date, description)
REQUEST MADE BY:
Name of requestor Daytime telephone number
STANDARD SIZE (8 1/2" X 11" OR 8 1/2" X 14")
Uniform copy fee $ No. of copies made x TOTAL CHARGE $
0.10 .
Address (if records are to be mailed):
* Reasonable fee established by agency
NON-STANDARD SIZE
Agency fee * $ No. of copies made x
Date / time of request Date / time filled Request filled by (name and title)
. .
TOTAL CHARGE
Signature Title
$
IF REQUEST IS NOT FILLED, STATE REASON (i.e., confidential by statute, etc.)
Date
DISTRIBUTION: White - Requestor; Canary - Cashier
PUBLIC RECORD COPY REQUEST
State Form 1365 (R3 / 11-99) Approved by State Board of Accounts, 1999 IC 5-14-3
LOCATION OF RECORD(S)
Department / Agency
Division / Institution
Section / Branch
PLEASE TYPE OR PRINT FIRMLY - YOU ARE MAKING 2 COPIES. RECORD(S) REQUESTED (identify by title, control number, date, description)
REQUEST MADE BY:
Name of requestor Daytime telephone number
STANDARD SIZE (8 1/2" X 11" OR 8 1/2" X 14")
Uniform copy fee $ No. of copies made x TOTAL CHARGE $
0.10 .
Address (if records are to be mailed):
* Reasonable fee established by agency
NON-STANDARD SIZE
Agency fee * $ No. of copies made x
Date / time of request Date / time filled Request filled by (name and title)
. .
TOTAL CHARGE
Signature Title
$
IF REQUEST IS NOT FILLED, STATE REASON (i.e., confidential by statute, etc.)
Date
DISTRIBUTION: White - Requestor; Canary - Cashier