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BOROUGH OF HELMETTA OPENPUBLICRECORDS ACT REQUEST FORM

51 Main Sfreef, Helmelta, NJ 08828 732-521 xl 00 (phone) -1.946 (tax) 732-605-9466 s.bohi nski@ltelm eltaboro.com Sandn Bohinski

lmportantNotice government records. Please read it carefully. rights concerning important information related to your Thelastpage of thisform contains Requestor Information - PleasePrint
First Name E-mailAddress Cash MailingAddress Fees: Check MoneyOrder Ml Last Name Select Payment Method

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Authorization Cost $

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Telephone PreferredDelivery: Pick Up US Mail On-Site Inspect

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lf you are requesting records containing perconal information, please circle one: Under penalty of N.J.S.A. 2C:28-3, I certiry that I HAW / HAVE NOT been convicted of any indictableoffense under the laws of New Jersey, any other state, or the United States.

Letter size pages - $0.05 per page Legalsize pages - $0.07 per page Other materials(CD, DVD, etc) - ac{ual cost of material Delivery: Delivery/ postage fees additional dependingupon delivery type. Extras: Special service charge dependentupon request.

Record Request Information: Please be as specificas possiblein describingthe recordsbeing requested. Also, pleasenote that your preferredmethodof deliverywill only be accommodated if the custodianhas the technological means and the integrityof the recordswill not such method of

AGENCYUSE ONLY

AGENCYUSE ONLY

AGENCYUSE ONLY