RIGHT-TO-KNOW REQUEST FORM

 

 

DATE REQUESTED: ____________________________

 

REQUEST SUBMITTED BY:   r E-MAIL r *U.S. MAIL*    r FAX        rIN-PERSON    

*Note:  Mailing address is Pocopson Township, P.O. Box 1, Pocopson, PA  19366

 

NAME OF REQUESTOR: _______________________________________________________

 

STREET ADDRESS::___________________________________________________________

 

CITY/STATE/COUNTY (Required): _______________________________________________

 

TELEPHONE (Optional):________________________________________________________

 

E-Mail (Optional) ______________________________________________________________

 

RECORDS REQUESTED:

*Provide as much specific detail as possible so the agency can identify the information.

 

____________________________________________________________________________

 

____________________________________________________________________________

 

____________________________________________________________________________

 

____________________________________________________________________________

 

DO YOU WANT COPIES?  r YES    or     r NO

 

DO YOU WANT TO INSPECT THE RECORDS?  r YES    or   r NO

 

DO YOU WANT CERTIFIED COPIES OF RECORDS? r YES    or      r NO

 

DO YOU WANT THE COPIES MAILED TO THE ADDRESS PROVIDED ABOVE OR WILL

YOU PICK UP THE COPIES AT THE ADMINISTRATION OFFICE?  r MAIL or r PICK UP

 

 

DATE RECEIVED BY THE AGENCY: ______________________________

 

AGENCY FIVE (5)-DAY RESPONSE DUE ON: _______________________

 

SIGNATURE RIGHT TO KNOW OFFICER: _____________________________________

 

**Public bodies may fill anonymous verbal or written requests.  If the requestor wishes to pursue the relief

and remedies provided for under the Right-to-Know Act, the request must be in writing. Written requests need

not include an explanation why information is sought or the intended use of the information unless otherwise

required by law.