FOIA Request Form

Requester's Name: __________________________________________________ ____________________________

Address: __________________________________________________ ____________________________
__________________________________________________ ____________________________

Phone Number (optional): __________________________________________________ ____________________________

Fax Number (optional): __________________________________________________ ____________________________

E-Mail (optional): __________________________________________________ ____________________________

Subject: __________________________________________________ ____________________________
__________________________________________________ ____________________________

In order to help to determine status to assess fees, select:

_ An individual seeking information for personal use
_ Affiliated with an educational or noncommercial institution, and this request is made for a scholarly purpose
_ Affiliated with a private corporation and seeking information for use in the company's business
_ A representative of the news media and this request is made part of news gathering and not for commercial use

Enter media name: __________________________________________________ ____________________________

Select type of Media:

_ Newspaper
_ Magazine
_ Television Station
_ Other

Purpose: __________________________________________________ ____________________________
__________________________________________________ ____________________________

Enter maximum amount you are willing to pay: $ __________________________________________________ ____________________________

Explanation for a request for a waiver of fees: __________________________________________________ ____________________________
__________________________________________________ ____________________________

Additional Comments: __________________________________________________ ____________________________
__________________________________________________ ____________________________

This form cannot be used for Privacy Act requests or requests for information about a third party.