Name: 
Company: 
Mailing Address: 
City:    State   Zip: 
Contact Number (between 9am-4pm): 
Preferred Delivery:  Pick up:      US Mail:    On-site Inspect:
Fax to: email to: 

Under penalty of N.J.S.A. 2C:28-3 I certify that I HAVE or  HAVE NOT been convicted of any indictable crime under the laws of New Jersey or any other state.  (check one)

Signature: ____________________________________

Date:  _____________________
 

Maximum Cost Authorized:

$

Fees:  8.5 x 11 (or smaller) @ $.05 ea.
            

           8.5 x 14  (or larger) @ $.07 ea.
             

Delivery:  Postage Fees are additional.

Disposition Notes:  Reason for denial or partial release:

Request Recv'd: __________    Total Cost:  _________
Date Delivered:  __________    Deposit: ____________
Balance Due:  ____________

Total Pages:  ________
Postage: ___________ 
Other Charges:  __________  Date Paid: ____________
Cash:  _________   Check #:  ____________

Custodian:

INFORMATION RELATED TO YOUR RIGHTS CONCERNING GOVERNMENT RECORDS 

PLEASE READ CAREFULLY 

1.         In order to request access to government records under the Open Public Records Act (OPRA), you must complete all the required portions of and date this form and deliver it in person during regular business  hours or by mail, fax, or electronically to the records custodian.  Your request is not considered filed until  the custodian of records has received the completed request form.  If you submit the form to any other officer or employee of Chesterfield Township, that officer or employee may not have the authority to accept your request form and your request will be directed to the Records Custodian.  The seven (7) business day response time will not commence until the Records Custodian receives the request form and determines it to be complete. 

2.         If you submit a request for access to government records to someone other than the Records Custodian, do not complete the request form, or attempt to make a request for access by telephone or fax; the Open  Public Records Act and its deadlines, restrictions and remedies will not apply to your request. 

3.         The fees for duplication of government records are listed on the front of this form.  Your will be notified of any special or additional charges prior to the processing of your request.  Payments by check or money order shall be made payable to “Chesterfield Township”. 

4.         When a request for copies is expected to exceed $20.00, you may be contacted by the Records Custodian for a deposit before the request will be processed.   

5.         Under OPRA, a records custodian must deny access to a person who has been convicted of an indictable offense in New Jersey or any other state, and who is seeking government records containing personal  information pertaining to the person’s victim or the victim’s family. 

6.         If Chesterfield Township is unable to comply with your request for access to a government record, the Records Custodian will indicate the reasons for denial in writing and forward it to you.   

7.         Except as otherwise provided by law or by agreement with the requestor, if the Records Custodian fails to respond to you within seven (7) business days of receiving the request form, the failure to respond will  be considered a denial of your request. 

8.         If your request for access to a government record has been denied or unfilled within the time permitted  by law, you have a right to challenge the decision of Chesterfield Township to deny access.  At your  option, you may either institute a proceeding in the Superior Court of New Jersey or file a complaint in  writing with the Government Records Council (GRC).  You may contact the GRC at 866-850-0511, by  mail at Post Office Box 819, Trenton, NJ 08625 or by e-mail at grc@dca.state.nj.us.  The Council can also answer other questions about the law. 

9.          Information provided on this form may be subject to disclosure under the Open Public Records Act.