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UTAH GOVERNMENT RECORDS REQUEST FORM TO: (Name of government office holding the records and/or name of agency contact person.) Address of government office: Description of records sought (records must be described with reasonable specificity): 9 I would like to inspect (view) the records. 9 I would like to receive a copy of the records. I understand that I may be responsible for fees associated with copying charges or research charges as permitted by UCA 63-2-203. I authorize costs of up to $ . 9 UCA 63-2-203 encourages agencies to fulfill a records request without charge. Based on UCA 63-2-203 I am requesting a waiver of copy costs because: 9 releasing the record primarily benefits the public rather than a person. Please explain: 9 I am the subject of the record. 9 I am the authorized representative of the subject of the record. 9 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. 9 I am the subject of the record. 9 I am the person who provided the information. 9 I am authorized to have access by the subject of the record or by the person who submitted the information. Documentation required by UCA 63-2-202, is attached. 9 Other. Please explain: 9 I am requesting expedited response as permitted by UCA 63-2-204 (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.) Requester’s Mailing Daytime telephone number: