REQUEST FOR RECORD INSPECTION / COPY
SMITH COUNTY, KANSAS

(To be completed by Requester)

NAME:                                                                                                                                              

ADDRESS:                                                                                                                                        

I, the undersigned, do not intend to, and will not use any list of names or addresses contained in or derived from the records or information requested for the purpose of selling or offering for sale any property or service to any person listed or to any person who resides at any address listed or for the purpose of solicitation of gifts or donations from any such person; neither will I sell, give or otherwise make available to any person any such list of names or addresses for any of the above purposes.

SIGNATURE:                                                                                                                  

RECORD(s) SOUGHT: Please provide as specific a description as possible of the record(s) you want to inspect/copy.  Include record titles and dates, as well as the names of county offices or departments which produced or hold the record(s):

No. of Copies (if desired)                         

1.                                                                                                                                                      

2.                                                                                                                                                      

CHARGES: A charge for providing access to public records is authorized by state law and has been established by the County Commission.  Theses charges are set at a level to compensate the County for the actual costs incurred in honoring your request.  The fee schedule established by the County is posted in this office.  The charge for access and / or copies of the record(s) you requested is estimated at
$                         .

PAYMENT MUST BE RECEIVED ON THE DAY OF REQUEST

Time of Request                                                

                                                                          
      Date                       Time                               Person Receiving Request

Records Provided                                              

                                                                         
     Date                        Time                              Person Providing Record

Staff Time Involved              hours,                  minutes for a charge of $                         

Charge for Copies Made $                         

Total Charges Due $                       

Record Custodian