Public Records Request Form CI I�1�Of �r,r
Spokane
1 Valley
Public Records Request
City Hall, 10210 E. Sprague Avenue
Spokane Valley, WA 99206
509-720-5102 phone 509-720-5075 fax
NAME OF PERSON REQUESTING INFORMATION:
(please print)
REQUESTER'S COMPLETE MAILING ADDRESS
ZIP CODE
REQUESTER'S CONTACT PHONE NUMBER:
REQUESTER'S Email:
PLEASE BE MINDFUL THIS IS A REQUEST FOR DOCUMENTS. So that we may better assist you, please be specific in
describing the documents you request. Include any additional information that will help us locate the documents you
seek, such as property address,dates, specific document (plans, permits)etc.
Check any that apply:
[ ] I wish a copy of the following documents [ ]I prefer to pick up the documents,please call when ready
[ ]I wish to review only(no copies)the following documents [ ]I prefer the documents be mailed to my address above
[ ]I wish to review the documents prior to having them copied [ ] Call me prior to making copies
PUBLIC DOCUMENTS OF THE CITY ARE PROVIDED FOR INSPECTION AND COPYING SUBJECT TO THE FOLLOWING:
1. No person shall knowingly alter,deface,or destroy public documents/records of the City.
2. Original public documents/records belong to the City and shall not be removed from the City office premises.
3. Care and safekeeping of public documents shall be the sole responsibility of the requester.
4. Documents furnished for public inspection or copying shall be returned in the same condition and in the same file sequence or
organization as when furnished.
5. A deposit of 10%may be required on public record requests.
6. It is the intent of the City to recover costs of providing public records when the total cost, including but not limited to the per-
page,device,envelope,or postage costs,amounts to$1.00 or more.Fees associated with providing records are on page 2.
It is the City's policy to respond within Eve (5)business days of receiving a public records request by either 1)providing the
document;2)acknowledging that the City has received the request and providing a reasonable estimate of the time the City will
require to respond to the request, to locate and assemble the documentation requested, to notify third persons or agencies affected
by the request, or to determine whether any ofthe information contained in any document requested is exempt,and that a denial
should be made as to all or part ofthe request or;3)denying the request. In acknowledging receipt ofa request that is unclear, the
City may ask the requester to clarify what is being sought.See Spokane ValleyMunicipal Code Title 2,Chapter 2.75.
Requester certifies that if the request is for a list of individuals,the information obtained through this request will not be used for
commercial purposes.
Signature Date
1
Public Record Request Form revised 1/2018
For City Official Use only
Action on request for public records will be taken within five (5) business days
❑ 1. Request received by: Date:
Employee's name
❑ 2. Responded to Request: letter, e-mail or other notification attached; or see comments below.
❑ 3. Notified requestor that documents are available on City's website. Date notified:
❑ 4. Forwarded to City Clerk for processing. Date:
❑ 5. Requestor withdrew request. Date ; Employee's name:
Comments:
FEE SCHEDULE: The City will recover costs of providing public records when the total cost, including but not limited
to the per-page, device, envelope, and/or postage costs, amounts to $1.00 or more.
Paper copies up to 11"x 17" (b/w or color): $0.15 per page
Paper copies greater than 11"x 17" (b/w or color): $0.87 per sf
Scanned copies of paper records: $0.10 per page
Electronic records uploaded to email, CD/DVD,
flash drive or cloud-based storage,: $0.05 per 4 files or attachments
Records transmitted in electronic format: $0.10 per GB
CD/DVD w/sleeve: $0.20 each
Flash drive (8GB): $7.99 each
Postage and Envelopes Actual Cost
Credit Card Transaction Processing Fee: 2.5%of Total Transaction
❑ DOCUMENTS REVIEWED ONLY. NO COPIES PROVIDED
Requester initials
❑ DOCUMENTS PROVIDED AS INDICATED BELOW:
A. # paper copies 11"X 17" or smaller: @$ 0.15 pg = $
#sf paper copies larger than 11"x 17": @$ 0.87 sf= $
# pgs: x (Size: x ) =# sf
# paper pages scanned to elect. format: @$ 0.10 ea = $
#electronic records uploaded to email,
CD/DVD, flash drive or cloud storage: @$0.05 p/4 files = $
#GB of attachment(s)transmitted: @$0.10 GB = $
B. SUPPLY COSTS:
#CD/DVD with sleeve: @$0.20 ea = $
# Flash drive (8GB): @$7.99 ea = $
C. MAILING COSTS:
Envelope: $
Postage: $
SUBTOTAL: $
D. Credit/Debit Card Processing Fee: @ 2.5% OF SUBTOTAL: $
TOTAL AMOUNT DUE: $
Date Documents Provided: Amount Paid: [] Cash [] Check/MO [] Credit/Debit
Funds Received by: (Employee name)
2
Public Record Request Form revised 1/2018