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Cumberland County Administration FOIA Request Form Attention: Stephany S. Johnson Post Office Box 110 / 1 Courthouse Circle Cumberland, Virginia 23040 Phone: (804) 492‐3625 Facsimile: (804) 492‐9224 [EMAIL REDACTED] Every effort will be made to expedite your request for information. Please be aware that some requests may involve duplicating large volumes of material or require research, so charges will be imposed. Please complete the information below and submit to the County Administrator’s Office. If you have any questions regarding the form or the procedure, please contact the County Administrator’s Office at (804) 492‐3625. Requestor’s Information Last Name First Name Company Name if applicable Street Address City State Zip / Phone Email Are you a resident of Virginia? □ Yes □ No I am requesting the following information: (Please be specific. This will assist us in processing your request and help to minimize your cost. Include details and a time frame of your request if applicable) □ I will pick up this information once I have been notified that it is ready. □ I would like this information to be mailed to me at the above address and understand that I will be responsible for postage charges. □ I would like this information, if possible, to be emailed to me at the email address provided above. understand that if I owe the County for a previous FOIA request, the County has the right to refuse to fulfill future FOIA requests until those fees are satisfied.**** Date Signature ---PAGE BREAK--- Internal Use Only Date Received: Received By: Due Date: Notes: