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FOR OFFICE USE ONLY
DETAILS OF REQUEST
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:
___
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
| 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 | $ | ||
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Labor Charges
Clerical time $
Professional time $
Outside contractors $
Total $
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Exhibit A
Estimated Costs of Response/Production
Description Quantity Amount Total
Format of Record(s)
Photocopies (black & white) ____/page
Photocopies (color) ____/page
USB Drive Actual Cost $
Postage Charges
Postage Actual Cost $
Labor Charges
Clerical time $
Professional time $
Outside contractors $
Total $
Explanation on fee estimate, where appropriate:
(Name, Title) on _____
Estimate given by
.(Date)
Estimate received by _____(Name) on _____.(Date)