Township of Woodbridge OPEN PUBLIC RECORDS ACT REQUEST FORM

One Main Street Woodbridge, NJ 07095 732-634-4500 732-602-6053 (fax) john.mitch@twp.woodbrldge.nj.us John M. Mitch, RMC, CMC, CMR, Munlcl I Clerk

Important Notice
The last page of this form contains important information related to your rights concerning government records. Please read it carefully.

Requestor Information - Please Print

First Name E-mail Address

Payment Information
Maximum Authorization Cost $

MJ

Last Name ___________________________ Select Payment Method Cash Check Money Order

Mailing Address --------------------- - - - - - - - - - - - - - - - - - - - - - - - - - - -- - City - - - - - - - - -- - State - - -- - - Zip _ _ _ _ _ _ ___ Telephone Preferred Delivery; Pick Up _ _ US Mail _ _ Letter size pages- $0.05 per page Legal size pages - $0.07 per page Other materials (CD, DVD, etc) -actual cost of material Delivery: Delivery I postage fees additional depending upon delivery type. Fees: Extras: Date Special service charge dependent upon request.

FAX
On-Site Inspect

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E-mail _ _ __

If you are requesting records containing personal information, please circle one: Under penalty of N.J.S.A. 2C:28-3, I certify that I HAVE I HAVE NOT been convicted of any indictable offense under the laws of New
Jersey, any other state, or the United States. Signature

Record Request Information: Please be as specific as possible in describing the records being requested . Also, please note that your preferred method of delivery will only be accommodated if the custodian has the technological means and the Integrity of the records will not be eo ardized b such method of delive .

--TOWNSHIP USE ONLY-Est. Records Fees Est. Postage Fees Est. Addt'l. Fees Est. Total Fees Deposit Amount Estimated Balance

--TOWNSHIP USE ONLY-Disposition Notes If any part of this request can not be provided in 7 days, requestor must be notified (see reverse side). Completed Partially Completed Denied
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--TOWNSHIP USE ONLY-Tracking # Rec'd Date _ _ _ _ __ Est. Ready Date _ __ Total Pages _ __ Documents Provided Finalized Cost

Total: Deposit: Balance Due : _ _ _ _ __ Balance Paid: _ _ _ __

Division Representative Signature Custodian Signature Date Request Completed Date