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2. Requester Information
4. First Name
5. Last Name
7. Address
9. City
10. State
11. Zip
13. Email Address
14. Phone Number
16. Fax Number
18. Note:
    Per Illinois statute, each request shall be answered by the City (by approval, denial or request for additional time to respond) within five (5) working days following receipt of the request.(5 ILCS 140/3(d)).
20. In the space below, please provide a detailed description of the information you are requesting.*
    (For example:date of incident, report number, type of incident/record, parties involved).
22. Do you wish...

    1. To inspect the records only?
       Note: You would not receive a copy of the records; you would only come to City offices to look at the records.
    2. To pick up a copy of the records?
       • Records of 50 pages or less may be picked up at no cost with your response.
       • Additional pages over 50 will be charged $.15 per page.
    3. To be mailed a copy of the records?
       • Records of 50 pages or less will be mailed at no cost with your response.
       • Additional pages over 50 will be charged $.15 per page.
    4. To receive a copy of the records by email (PDF Format)?
    5. To receive a copy of the records by fax?
24. Additional Option:

    1. Do you wish to have the records certified?

    Note: A certification is a document stating that the records being provided are a true copy of the requested records. A certification fee of $1.00 applies and must be prepaid.
26. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your request will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
28. Electronic Signature*
Leave This Blank:


30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit

* indicates a required field