APPLICATION FOR PUBLIC ACCESS TO RECORDS
RECORDS ACCESS OFFICER
Name of Agency _ Request Number ___________________________________________________________
Address
I HEREBY APPLY TO INSPECT THE FOLLOWING RECORD:
_______________________________________________________
_______________________________________________________
_______________________________________________________
Name _ Representing _____________________________________
Mailing Address _ Telephone Number ___________________________________________________________
Signature _ Date _________________________________________
FOR AGENCY USE ONLY
APPROVED
DENIED (for the reason(s) checked below)
___Confidential Disclosure __ Part of Investigatory Files
___Unwarranted Invasion of Personal Privacy
___Record of Which This Agency is Legal Custodian Cannot Be Found
___Record is not Maintained by This Agency
___Exempted by Statute Other Than the Freedom of Information Act
___ Request has been Referred to Department Which has Custody or Control of Original Record
___ Other (specify) ___________________________________________
Signature
_______________________________________________________
Title
Date
NOTICE: YOU HAVE A RIGHT TO APPEAL A DENIAL OF THIS APPLICATION TO THE HEAD OF THIS AGENCY OR HIS DESIGNEE WHO IS:
Name _ Business Address __________________________________________________________
WHO MUST FULLY EXPLAIN HIS REASONS FOR SUCH DENIAL IN WRITING WITHIN SEVENWORKING DAYS OF RECEIPT OF AN APPEAL
I Hereby Appeal:
Signature _ Date _________________________________________
N.Y. Comp. Codes R. & Regs. Tit. 13 § 120.10