===== PAGE 1 ===== # 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 < table border = 1 style = 'margin: auto; word-wrap: break-word;' > < tr > < td colspan = "2" > Description < /td > < td style = 'text-align: center; word-wrap: break-word;' > Quantity < /td > < td style = 'text-align: center; word-wrap: break-word;' > Amount < /td > < td style = 'text-align: center; word-wrap: break-word;' > Total < /td > < /tr > < tr > < td colspan = "2" > Format of Record(s) < /td > < td style = 'text-align: center; word-wrap: break-word;' > < /td > < td style = 'text-align: center; word-wrap: break-word;' > < /td > < td style = 'text-align: center; word-wrap: break-word;' > < /td > < /tr > < tr > < td style = 'text-align: center; word-wrap: break-word;' > < /td > < td style = 'text-align: center; word-wrap: break-word;' > Photocopies (black amp; white) < /td > < td style = 'text-align: center; word-wrap: break-word;' > < /td > < td style = 'text-align: center; word-wrap: break-word;' >0.25/page$Photocopies (color)$0.50/page$USB Drive$10.00 each$Postage ChargesPostageActual Cost$ ===== PAGE 2 =====

Labor Charges
	Clerical time		$
	Professional time		$
	Outside contractors		$
		Total	$

===== PAGE 3 ===== ## Exhibit A Estimated Costs of Response/Production

Description		Quantity	Amount	Total
Format of Record(s)
	Photocopies (black & white)		____/page < /td > < td style = 'text-align: center; word-wrap: break-word;' >
	Photocopies (color)		____/page < /td > < td style = 'text-align: center; word-wrap: break-word;' >
	USB Drive		Actual Cost	$
Postage Charges
	Postage		Actual Cost	$
Labor Charges
	Clerical time			$
	Professional time			$
	Outside contractors			$
			Total	$

Explanation on fee estimate, where appropriate: 。 Estimate given by (Name, Title) on _____ .(Date) Estimate received by _____(Name) on _____.(Date)