Standard Right-to-Know Law Request Form

Please read carefully. Complete this form and retain a copy of both pages; this copy may be required if an appeal is filed. You have 15 businessdays to appeal after a request is denied or deemeddenied.More information about the RTKL is available at https://www.openrecords.pa.gov. In most cases, a completed RTKL request form is a public record.

SUBMITTED TO AGENCY NAME: ____________________________________________________________________(Attn: AORO)

DateRequestSubmitted: ________________________Submittedvia: □Email □U.S.Mail □Fax □In Person

PERSON MAKING REQUEST:

Full Name: _____________________________________________________________________________________________________________

Company (if applicable): ____________________________________________________________________________________________

Please send response via: □ Email □ U.S. Mail

If you wish to obtain records that only exist in hard copy, or must be provided on an electronic storage device, you may be required to provide a mailing address to the agency. See Section 703.

Email: __________________________________________________________________________________________________________________

Mailing Address: ______________________________________________________________________________________________________

City:_________________________________State:________ Zip:______________ Telephone:__________________________________

How do you prefer to be contacted if the agency has questions? □ Telephone □ Email □ U.S. Mail

□ By checking this box, I affirm that my full name and contact information is true and correct, and that I am a legal resident of the United States. I understand that failure to check this box may result in the denial of my request and the dismissal of any appeal filed with the Office of Open Records.

RECORDS REQUESTED: Provide as much detail as possible, including subject matter, time frame, and type of record sought. RTKL requests must seek records, not ask questions. Use additional pages if necessary.

Form continues on page 2. Retain a copy of both pages.

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RECORDS REQUESTED (continued):

DO YOU WANT COPIES?	□ Yes, printed □ Yes, electronic □ No, in-person inspection

Records shall be provided in the medium requested if they exist in that medium; otherwise, they shall be provided in the medium in which they exist. See Section 701. Your request may require payment or prepayment of fees. View the Official RTKL Fee Schedule for more details.

I understand that my request may incur fees. Notify me before further processing if fees will be more than □ $100 (or) □ $____________.

Do you want certified copies? □ Yes (may be subject to additional costs) □ No

ITEMS BELOW THIS LINE FOR AGENCY USE ONLY

Tracking: ____________________ Date Received: ____________________ Response Due (5 bus. days): ____________________

30-Day Ext.? □Yes □No (If Yes, Final Due Date: ___________________) Actual Response Date:____________________

Request was: □ Granted         □ Partially Granted & Denied         □ Denied         Cost to Requester: $_____________________

□Appropriate third parties notified and given an opportunity to object to the release of requested records.

Retain a copy of both pages of this Form.

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