| | State of New Jersey | | | | BOROUGH OF HOPEWELL | | | GOVERNMENT RECORDS REQUEST FORM | | | | | Important NoticeThe reverse side of this form contains important information related to your rights concerning government records. Please read it carefully. |
| | Requestor Information – Please Print | Payment Information | First Name | | MI | | Last Name | | Company | | Mailing Address | | City | | State | | Zip | | Email | | Business Hours Telephone: | Area Code | | Number | | Extension | | Preferred Delivery: | Pick Up | | US Mail | | On Site Inspect | | | Circle One: Under penalty of N.J.S.A. 2C:28-3, I certify that I HAVE / HAVE NOT been convicted of any indictable offense under the laws of New Jersey, any other state, or the United States. | Signature | | Date | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
| | Maximum Authorization Cost $ | | | Select Payment Method | | Cash | | Check | | Money Order | | | Fees: | 8 1/2 x 11" | @$0.05 | | 8 1/2 x 14" | @$0.07 | | | | Delivery: | Delivery / postage fees additional depending upon delivery type. | Extras: | Extraordinary service fees dependent upon request. | | | | | | | | |
| | Record Request Information: To expedite the request, be as specific as possible in describing the records being requested. Also, please include the type of access requested (copying or inspection), and if data, the medium requested. | | | AGENCY USE ONLY | | AGENCY USE ONLY | | AGENCY USE ONLY | Est. Document Cost | | | Est. Delivery Cost | | | Est. Extras Cost | | | Total Est. Cost | | | Deposit Amount | | | Estimated Balance | | | | | | Deposit Date | | | | | | | | |
| | Disposition NotesCustodian: If any part of request cannot be delivered in seven business days,
detail reasons here. | | | | | | In Progress | - | Open | | Denied | - | Closed | | Filled | - | Closed | | Partial | - | Closed | |
| | Tracking Information | Final Cost | Tracking # | | | Total | | Rec’d Date | | | Deposit | | Ready Date | | | Balance Due | | Total Pages | | | Balance Paid | | Records Provided | | | | | | | | | | | Custodian Signature | | Date | | | | | | | | |
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