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Town of Mansfield

4 South Eagleville Road
Mansfield, CT 06268
www.mansfieldct.gov

FREEDOM OF INFORMATION ACT REQUEST

 Date:  
 Name:  
 Address:  
 Phone #:      
 Email:  

Please describe with specificity the document(s) you are requesting.  If you are not sufficiently specific, we may not be able to identify the document(s) you request which may delay our response to your request:

 

I want to (please check one):

   Review Records at Town Hall (vault in Town Clerk's Office
   Receive Hard Copies of Requested Documents
   Other (please specify)

 

I agree to pay such fees and costs noted in the Town of Mansfield FOI Fee Schedule prior to the release of documents to me.  I understand that materials may be picked up and payment made at the Town Clerk's Office.  I understand that the fees may be waived if I, the requester, am receiving public assistance or can demonstrate other facts showing my inability to pay due to indigence.

Signature of Requester (type your name) 

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Department use only
Date Request Received:_____________________                Date Picked-Up:____________________________
Docs. Returned to TC:    _____________________                Date Completed:____________________________
# of Pages:                       _____________________               Cost:                     $___________________________

Notes:

Revised 8/30/12