FOR OFFICE USE ONLY

DETAILS OF REQUEST

1. Date and Time Request Received: ___
2. Request Received by: _____ (Name, Title)
3. Estimated costs of response, calculated as set forth in Exhibit A, attached hereto. Determined by: ___(Name, Title)
4. Estimated costs received: _____ (date) in the amount of $_____ by _____ (Name, Title)
5. Date and Time Request Processed: ___
6. Other relevant information: ___

NOTIFICATION OF RECORDS BEING AVAILABLE / FINAL COSTS

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 ___

FEE WORKSHEET