Dear Clerk Treasurer

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Pursuant to the Indiana Access to Public Records Act (IC 5-14-3), I would like to FIELD A of the following public records: FIELD B, FIELD C, FIELD D

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I understand that if I seek a copy of this record, there will be a copying fee of 0.10 per page.

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According to the statute, you have 24 hours to respond to this request. If this letter was delievered personally to the public official's office, the agency has 24 hours to respond to the request. If the letter is delivered by US mail of facismile, the agency has seven days to respond to the request. If you choose to deny the request, then you are requried to respond in writing and state the statutory exception authorizing the whitholding of all or part of the public record and the name and title or position of the person responsible for the dential.

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Thank you for you assistance.

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Respectfully,

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FIELD E

FIELD F

FIELD G

FIELD H