REQUEST FOR INFORMATION FORM

Pursuant to the Pennsylvania Right to Know Act

and Borough Ordinance 727

(Revised 12/30/08)

Name of Requestor: _____________________________________________________

(Please Print)

Address: _______________________________________________________________

Street City State Zip

Telephone Number: ______________________________________________________

Information Requested (please be specific): __________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Date: _____________________ Signature: __________________________

Do Not Write Below This Line – For Official Use Only

Information availability:

Date: __________________________________________

Place: __________________________________________

Time: __________________________________________

Information unavailable:

Reason: ________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________

Cost:

Duplication $.25 per page x _______ = __________

Postage = __________

TOTAL DUE = __________

Fee received: $ _______ Date: ____________________________________

Borough Administrator: __________________________________________________