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REQUEST FOR RECORD – UTAH GOVERNMENT RECORDS ACCESS & MANAGEMENT ACT TO: (Name of government office holding the records and/or name or agency contact person.) Address of government office: Description of records sought (records must be described with reasonable specificity): I would like to: View or inspect the records only. Receive a copy of the records and pay associated fees. Please notify me if the amount will exceed Receive a copy of the records and request a fee waiver according to Utah Code §63G-2-203 because: releasing the record primarily benefits the public rather than a person. Please explain: I am the subject of the record. I am the authorized representative of the subject of the record. My legal rights are directly affected by the record and I am impoverished. (Please attach information supporting your request for a waiver of the fees.) If the requested records are not public, please explain why you believe you are entitled to access: I am the subject of the record. I am the person who provided the information. I am authorized to have access by the subject of the record or by the person who submitted the information. Documentation required by UCA §63G-2-202. Other. Please explain: I am requesting an expedited response (5 days). (Please attach information that shows your 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 that demonstrates that you are entitled to expedited response.) Requestor’s Name: Mailing Address: Daytime telephone number: Email address: Signature: Date: