RIGHT-TO-KNOW REQUEST FORM

TO:     OPEN-RECORDS OFFICER
            STROUD TOWNSHIP
            1211 N. FIFTH ST.
            STROUDSBURG, PA  18360

 DATE REQUESTED:                

REQUEST SUBMITTED BY:           E-MAIL             U.S. MAIL       FAX       IN-PERSON       

NAME OF REQUESTOR:______________________________________                         ____________      

STREET ADDRESS:_____________________________________________      __________________

CITY/STATE/ZIP CODE (Required): _____________________________________________________

TELEPHONE (Optional):________________________________________

 RECORDS REQUESTED: *Provide as much specific detail as possible so the agency can identify the information. 
Attach additional page(s) if this space is not large enough to make a complete and thoroughly detailed request.    

DO YOU WANT COPIES AT A COST OF 25 CENTS PER PAGE? YES or NO
(The rate of 25 cents applies to one side of a sheet of white copy paper up to 11” x 17”; larger copies will be at market rate.)

DO YOU WANT TO INSPECT THE RECORDS BEFORE DECIDING ON HAVING COPIES MADE?  YES or NO

DO YOU WANT CERTIFICATION OF THE COPIES OF RECORDS AT A COST OF $10? YES or NO

(FOR AGENCY USE ONLY)

RIGHT TO KNOW OFFICER:
DATE RECEIVED BY THE AGENCY:
AGENCY FIVE (5) BUSINESS DAY RESPONSE DUE: