Jt. Jerome School District #261

COMMUNITY RELATIONS 4260F

District Record Request Form

Request for Public Records

I request:  ____ to examine  ____ to copy  ____ to receive an electronic copy

of the following records (please be as specific as possible):

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

Date Records Requested Were Created:

Beginning: ________________________________________________________________

Ending: __________________________________________________________________

Name (Please Print) __________________________________________________________________

Mailing Address:

________________________________________________________________________________________________

____________________________ ______________________________________________________

Date of Request Daytime Phone Number

Received By: ______________________________________ Date Received: ________________________________

Public Agency __________________________________________

_____ Initial if Applicable: More than three (3) working days are needed to locate or retrieve the requested records. A response shall be provided within ten (10) working days of the request, unless the field below has been initialed.

_____ Initial if Applicable: The record requested must be converted from one electronic format to another and doing

so will require more than ten working days. The agency shall provide the converted public record at the following time, which has been mutually agreed upon between the agency and the requester, which due consideration given to any limitations that may exist due to the process of conversion or due to the use of a third party to make the conversion.

Payment received for________________ copies___________________ Amount Received ________________________

Payment received for__________________ labor___________________ Amount Received _______________________

___________________ ___________________

Receipt Number Date

Policy History:

Adopted on: 09/27/2011

Revised on: 12/15/2015

Revised on: 01/26/2021

Revised on: 02/28/2023