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2. Date
   Date

   Date
4. First Name
5. Last Name
7. Phone Number
8. Fax Number
10. Email Address
12. 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.
14. I want to (please check one):

    1. Review Records at Town Hall (vault in Town Clerk's Office)
    2. Receive Hard Copies of Requested Documents
    3. Other (please specify)
16. 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.
18. Signature of Requester (type your name)
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20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit

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