FOR OFFICE USE ONLY
Date and Time Request Received: ___
Request Received by: _____ (Name, Title)
Estimated costs of response, calculated as set forth in Exhibit A, attached hereto. Determined by: ___(Name, Title)
Estimated costs received: _____ (date) in the amount of $_____ by _____ (Name, Title)
Date and Time Request Processed: ___
Other relevant information:
___
Requestor notified on ___(date) by: ___(Name, Title)
___ Phone ___ Email ___ In Person
___ Records ready for collection on ___
___ Examination of original records scheduled for ___
___ Records mailed/faxed/emailed to requestor on ___
| Description | Quantity | Amount | Total |
|---|
| Format of Record(s) | | | |
| Photocopies (black & white) | | $0.25/page | $ |
| Photocopies (color) | | $0.50/page | $ |
| USB Drive | | $10.00 each | $ |
| Postage Charges | | | |
| Postage | | Actual Cost | $ |