**Note to Requester: Retain a copy of this request for your files. If you eventually need to file a Request for Review with the Public Access Counselor, you will need to submit a copy of your FOIA request.** Date Requested Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20172018201920202021 Name of Requester * Street Address * City/State/County Zip * Telephone Email Fax Number Records Requested*Provide as much specific detail as possible so the public body can identify the information that you are seeking. You may attach additional pages, if necessary. Do you want copies of the documents? * Yes No How do you want your copies? * Electronic Copies Paper Copies If Electronic, what format would you prefer? * Is this request for a Commercial Purpose? * Yes No (It is a violation of the Freedom of Information Act for a person to knowingly obtain a public record for a commercial purpose without disclosing that it is for a commercial purpose, if requested to do so by the public body. 5 ILCS 140.3.1(c)). Are you requesting a Fee Waiver? * Yes No (If you are requesting that the public body waive any fees for copying the documents, you must attach a statement of the purpose of the request, and whether the principal purpose of the request is to access or disseminate information regarding the health, safety and welfare or legal rights of the general public. 5 ILCS 140/6(c)).