HomeMy Public PortalAboutFreedom of Information Act (FOIA) Request Form
City of Riverdale, Iowa 110 Manor Drive, Riverdale, Iowa 52722 • (563) 355-2511 • www.riverdaleia.org
CITY OF RIVERDALE, IOWA
RECORDS REQUEST FORM
REQUESTER INFORMATION
Name
Company Name
(if applicable)
Address
City State Zip
Phone Email
DESCRIPTION OF RECORDS REQUEST
Please be as specific as possible: include dates, subjects, resolution numbers, project names, key words, etc.).
Use additional pages if necessary.
Iowa Code Chapter 22 gives every citizen the right to examine public records and to copy those records unless their access is
expressly prohibited. The City of Riverdale staff should not be expected to abandon or neglect their regular public duties t o
comply with records requests and thus need sufficient time to make and deliver any requested information. If the requested
material potentially contains confidential information or is otherwise exempt from disclosure, additional time may be required
for review and possible redacting of material. All requests will be processed in accordance with applicable procedures and
rules. NOTE: If a deposit is required, no work will begin on the request until the deposit is received.
SIGNATURE & DATE
Signature Date
City of Riverdale, Iowa 110 Manor Drive, Riverdale, Iowa 52722 • (563) 355-2511 • www.riverdaleia.org
FOR OFFICE USE ONLY
Request Format ☐ Written: ☐ Email ☐ Fax ☐ Mail ☐ In-Person
☐ Verbal: ☐ Telephone conversation ☐ Voicemail ☐ In-Person
Requesting To ☐ Have copies ☐ View originals
Request Received Date / / Time : AM / PM
Request Processed Date / / Time : AM / PM
10 Business Days from Request Date / / Time : AM / PM
NOTE: A reasonable delay is permissible to determine if the record is a confidential record, but the delay shall not exceed
twenty (20) calendar days and ordinarily should not exceed ten (10 business days.
20 Calendar Days from Request Date / / Time : AM / PM
Date Legal Counsel's Opinion Sought / /
Estimate of Fees (if applicable) $ Deposit Retained
(if applicable) $
NOTIFICATION
☐ Documents are ready for pick up at City Hall during regular business hours
☐ Documents are ready for pick up at City Hall by special appointment
☐ Documents are ready for examination at City Hall during regular business hours
☐ Documents are ready for examination at City Hall by special appointment
☐ Documents are being mailed to the submitter via certified mail at the above address at
the submitter's expense
First Notification
Date / / Time : AM / PM
☐ Email ☐ Telephone ☐ Voicemail ☐ In-Person
Second Notification
Date / / Time : AM / PM
☐ Email ☐ Telephone ☐ Voicemail ☐ In-Person
FEES
☐ Copy Charges: Photocopies (5 pages free annually): $0.25/page x __________ pages = $____________________
Printed pages: $0.10/page x __________ pages = $____________________
☐ Fax Charges: $1.00/page x __________ pages = $____________________
☐ Digital Charges: PDFs $0.10/page x __________ pages = $____________________
Compact Discs $3.50/CD x __________ CDs = $____________________
Audiotapes $7.00/tape x __________ tape = $____________________
☐ Other: (please specify): a ctual cost = $____________________
☐ Other: (please specify): actual cost = $____________________
☐ Postage: actual cost = $____________________
City of Riverdale, Iowa 110 Manor Drive, Riverdale, Iowa 52722 • (563) 355-2511 • www.riverdaleia.org
☐ Staff Services:
(15 minutes free weekly) $3.75 to $6.00/15 minutes x __________ increments of 15 minutes = $____________________
Initials of employee performing service: ______________________
TOTAL FEES: $__________________________
Less Deposit: $__________________________
AMOUNT DUE: $__________________________ PAID ON: ____________________________________
ACCEPTANCE & RECEIPT
Documents received and acknowledged:
Recipient's Name Printed
Recipient's Signature
Date
City of Riverdale Records Custodian Signature