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August 2017 GRAMA – Records Request Form To the City of Millcreek: Description of records requested: (Be as specific as possible; type of records, subject, year or dates wanted, etc.) Check all that are applicable: I would like to review/inspect the records. I would like to receive copies of the records. I understand that I will be responsible for copy costs. I authorize costs of up to I understand that prepayment of copies over $50.00 may be required and that I will be contacted if estimated costs are greater than the above specified amount. I would like to receive copies of the records and request a waiver of costs under UCA 63G-2-203(4). Supporting documentation is attached. If the requested records are not Public, please explain why you believe you are entitled to access. I am the subject of the record. (Photo ID required) I am the person who submitted the record (Photo ID required) I am authorized to access the record by the subject of the record. (Consent for Release Form attached). Other. Please explain. I am requesting an expedited response as permitted by UCA 63G-2-204(3)(b). (Please attach information showing status as a member of the media and a statement that the records are required for a story for broadcast or publication, or other information demonstrating entitlement to an expedited response.) Name of Street Address: City: State: Zip Code: Daytime phone number where requestor can be reached: Signature: Please note: state law does not require any agency to create any record to fulfill a request. GRAMA applies only to existing records. In some cases, you may need to provide a Social Security Number or other personal identifier to retrieve records. In the case of a request for medical records, the agency may require you to complete a HIPAA release. DO NOT include your Social Security Number on this form. The agency will provide a separate method for you to provide that number if it is needed.