City of Page | Records Request Form

* Required field

Date: *

Records Request Form

Thank you for your interest in Page City Government. A written request assists us in providing a complete and accurate response. Your request will be handled as soon as possible depending on sources and complexity of the information needed. Fees charged are set forth in Resolution No. 1100-12 (Exhibit "A" attatched.) You will be contacted for payment contigent upon results of your request. Health information requests for someone other than yourself must include a patient signed HIPAA form.

Requesting Party *

Mailing Address: *

City: *

State: *

Zip: *

Phone: *

FAX Number:

Email Address: *

List specifically the documents or information desired: *

Reason for information request: *

General information or research purposes

Commercial purposes*

*Please note, certain legal restrictions exist on the commercial use of governmental information.

Explain commercial use intended

HIPAA Form (if applicable)

EXHIBIT “A”

Copying/duplication fees:

Standard sheet (8½" x 11") – .25¢ per side
Legal street (8½" x 14") – .30¢ per side
11" x 17" – .35¢ per side

Large format fees:

18" x 24" – $4.00 paper – $8.00 mylar
24" x 36" – $5.00 paper – $12.00 mylar
36" x 48" – $7.00 paper

Other Medium:

Audio tape – $7.00
CD/DVD – $15.00
Fax – $1.00 per page

PAGE POLICE AND FIRE DEPARTMENTS:

Copying/duplication fees:

Criminal/accident/misc. reports – $10.00
CD/DVD (audio/photo/video) – $20.00
Finger prints – $10.00

COMMERCIAL PURPOSE FEES:

A reasonable fee shall be charged for the cost of time, materials, equipment, and personnel in producing duplications.

Office use only:

Date Completed:

By:

Duplication Fee Amount:

FAX/Postage Fee Amount:

Total Amount:

No. Page Copies:

Copied By:

Comments:

Please confirm your signature by typing your full name in the box below.

I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature.