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Request for Inspection of Public Records

2. Response / Fulfillment Times
   Response or fulfillment by the City of Pacific of this request will occur within 72 hours from the time requested.

   Response or fulfillment by the City of Pacific of this request will occur within 72 hours from the time requested.

4. Date & Time of Request
   Date & Time of Request

   Date & Time of Request

6. Records Being Requested

8. For Inspection Only?

   1. Yes
   2. No

9. Copy of Records Requested?

   1. Yes
   2. No

10. Number of Copies Requested

12. Requested By:

13. Telephone Number

15. Street Address

17. City

18. State

19. Zip

21. Date Request Received
    Date Request Received

22. Person Accepting Request

24. Request Received:

    1. By Mail
    2. By Phone
    3. Walk-In

25. Fees

    1. Yes
    2. No Charge

26. Cost to Provide Copy

27. Date Record Provided
    Date Record Provided

29. Place, Time & Date Record Available for Inspections

31. Explanation for Cause in Delay, if Applicable

33. If Request to be Denied, Request Forwarded to City Clerk for Denial

    1. Forwarded

35. Date Reqquest Received for Written Statement of Grounds for Denial
    Date Reqquest Received for Written Statement of Grounds for Denial

36. Date Written Statement by City Clerk Explaining Denial Provided
    Date Written Statement by City Clerk Explaining Denial Provided

    Date Written Statement by City Clerk Explaining Denial Provided

Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field