J. Robert Jamerson Memorial Library
Freedom of Information and Records
10.3 Request for Public Records
Patron____________________________________________ Date________________
Address____________________________________________
Phone Number________________________________________
Description of Requested Record(s)
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Please indicate that if you wish to inspect the above records or wish a copy of them
◻ Inspection ◻ Copy ◻ Both
Do you wish to have copies certified?
◻ Yes ◻ No
This request is being made in accordance with the provisions of the Virginia Freedom of Information Act and the undersigned agrees to abide by the Rules and Regulations, and to pay all charges* involved with the copying of the documents including postage costs
Signed________________________________________________________ Date________________
Submit request to:
Freedom of Information Officer
J. Robert Jamerson Memorial Library
157 Main Street, P.O. Box 789
Appomattox, Virginia 24522
Telephone: (434) 352-5340
Fax: (434) 352-0933
The requestor will be charged twenty cents ($.20) for each copy of requested materials. In order to provide certified copies of the requested materials, the Library will charge an additional $2.00 per copy. Copies of public records shall be provided to the requestor upon payment of any copy or postage charges, which are due. In the event that the charges for copies of public records is more than $3.00, the Freedom of Information Officer shall require that advance payment be made in full. Written confirmation from the requestor will be required for charges over $25.00.
For office Use Only
Date Received________________ Date Response Due________________
◻ Request Approved ◻ Request Partially Approved
◻ Request Denied ◻ Request Deferred