FOIA Form

Freedom of Information Act Request

Name*:

Organization Name:

Address 1:

Address 2:

City:

State:

Zip:

Phone Number:

Email Address:

Short Description of Request*:

Records Requested:

What is your intended use of the data requested?

If requesting personally identifiable information (PII), please select which reason best explains your request:

For use by any government agency in carrying out its function

For a business to verify the accuracy of personal information previously provided to the business

To use in any court proceeding or investigation in anticipation of litigation

For research and statistical purposes so long as the personal information is not publish, redisclosed, or used to contact individuals

For use by an insurer for claims investigations, rating, and underwriting

Supporting Document: