Name:

Street Address:

City:

State:

Zip Code:

Phone:

Email Address:

I do hereby request to inspect the following specified public records in accordance to KRS 61.884 which allows for the inspection of public records upon written application.

Requested Records:

I understand that copies of written material in public records are available on payment of a fee of ten cents a page; copies of non-written records (photographs, maps, material stored in a computer file or libraries, etc.) shall be furnished on request, at charge equal to the actual cost of producing copies of such records by the most economic process not likely to damage or alter the record.

Date:

Signature: