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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.
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:


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

    This field is not part of the form submission.

40. Submit

* indicates a required field