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Public Information Request Form

application for information or records


TO THE CUSTODIAN OF RECORDS FOR THE CITY OF LAMESA,
DAWSON COUNTY, TEXAS


NAME OF APPLICANT: ___________________________________________________________


ADDRESS: _____________________________________________________________________


PHONE NUMBER(S): __________________________________________________________


PLEASE LIST AND DESCRIBE SPECIFIC DETAILS OF DOCUMENTS REQUESTING FOR COPIES,

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I hereby acknowledge that certain exceptions to disclosure exist under the Texas Law to protect against disclosure of exempt information.  If it appears that an exception to disclosure of such records exist, an opinion  will be sought from the Attorney General’s office within ten (10) business days from receipt of a request for information.  Other information is simply confidential and will be redacted from any records disclosed.  Additionally, I will be responsible for the costs associated with the request made hereby.

_________________________________                   _________________________________

Applicant’s Signature                                               Date of Request

I acknowledge that I have received documents described above.

________________________________                   _______________________________

Applicant’s Signature                                             Date Received

REQUEST APPROVED/DENIED BY ______________________ DATE___________________

Request Denial Reason: ________________________________________________________

If Request for Opinion of Attorney General, Date Requested: __________________________

Amount Due: $___________________________    Amount Paid: $_____________________

Date Request Due By: _____________________   Date Request Closed:_______________