COMMONWEALTH OF KENTUCKY
REQUEST TO INSPECT PUBLIC RECORDS RE: KRS CH. 61
TO: (Name of library) ____________________________________
DATE:_____________________
Name of person making request:_______________________________________________________________ Address (if material is to be mailed): ___________________________________________________________ City: _____________________________________ State:________ Zip code:___________________________ 1. I request inspection of the following document(s):___________________________________________________________________________________ _____________________________________________________________________________________________
_____________________________________________________________________________________ 2. Number of copies of each document requested @ 10¢ a page: ________________________________________ 3. Enclosed $_________________________
Check [ ]
4. Is requested information from a database: 5. For commercial use:
Yes [ ]
Money Order [ ] Yes [ ]
Cash [ ] No [ ]
No [ ]
6. If the answer to questions 5 & 6 is yes, the commercial purpose for which the requested information shall be used to:___________________________________________________________________________________________ I hereby certify that the information set forth in item 7 is true and correct to the best of my knowledge. Signature:____________________________________________________________________________ ________ 8. (Library staff) The following disposition was made of the above request:____________________________________
9.
Signature of Amount Received:_________________________________ Director:___________________________________ Date mailed:_________________________________
Date:____________________________________________
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