Schaumburg Township Request for Public Record Form

Request for Public Record Form
Freedom of Information Act, Authority: 5 ILCS 140, et seq.

If you prefer to print out and mail this form with your payment please mail it to:

Township of Schaumburg
One Illinois Blvd.
Hoffman Estates, IL 60169-3314

Please complete the following information.	*Required Form Fields.

Requestor’s Name:*	(LAST, FIRST, M.I., CO. Represented)
Requestor’s Address:	(STREET, CITY/STATE, ZIP)
Requestor’s Phone No:	(WHERE YOU CAN BE REACHED MON.-FRI., 8:30 A.M. TO 5:00 P.M.)
Requestor’s Fax No:
Email Address:*

Format:	Email (e.g. PDF, Excel, Word, etc.)
	Electronic (e.g. CD/Rom, Diskette etc.)
	USPS Standard Mail
	Inspect Records at Township Office
	Obtain Hard Copy of Records
	Certification
Comments:

PLEASE ALLOW SEVEN (5) WORKING DAYS TO PROCESS ALL REQUESTS

Information Requested
(Please be specific with your request)

Describe Item Requested:
Date(s) of Occurrence:

Purpose:
(e.g. commercial)

The first 50 pages of a black-and-white document will be free of charge. All subsequent pages will be charged at 15 cents per page. Color copies will be charged at the actual cost of reproducing color copies. A record requiring certification will be charged at $1.00 per record.

INFORMATION RECEIVED:

DATE

PRINT NAME	SIGNATURE