Government Records Request Form - Township Of Hillsborough
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4TOWNSHIP OF HILLSBOROUGH
GOVERNMENT RECORDS REQUEST FORM
379 SOUTH BRANCH ROAD
HILLSBOROUGH, NJ 08844
908-369-3535 PHONE
908-369-6034 FAX
Pamela Borek, Township Clerk
Important Notice
The following pages of this form contain important information related to your rights concerning government records. Please read carefully.
Requestor Information - Please Print
Payment Information
First Name ___________________________ MI _______ Last Name ______________________________
Maximum Authorization Cost $
Email Address _________________________________________________________________________
Select Payment Method
Mailing Address ________________________________________________________________________
Cash
Check
Money Order
City ________________________________________ State ________________ Zip _________________
Fees: 8.5” x 11” = $0.05
8.5” x 14” = $0.07
Record Request Information: Please be as specific as possible in describing the records being re
Telephone __________________________________ Fax ______________________________________
Other – Call for pricing
preferred method of delivery will only be accommodated if the cusl mea
Delivery: Delivery / postage fees
ized by such method of delivery.
Preferred Delivery:
Pick Up
US Mail
On-Site Inspect
Fax
Email
additional depending upon delivery
type.
If you are requesting records containing personal information, please select one: Under penalty of N.J.S.A.
2C:28-3, I certify that I
HAVE /
HAVE NOT been convicted of any indictable offence under the laws of
Extras: Special service charge
New Jersey, and other state or the United States.
dependent upon request.
Signature __________________________________________ Date ______________________________
Record Request Information: Please be as specific as possible in describing the records being request.
AGENCY USE ONLY
AGENCY USE ONLY
AGENCY USE ONLY
Tracking Information
Final Cost
Date
Est. Document Cost __________
Disposition Notes
Tracking # ______________ Total ________________
Custodian: If any part of request cannot
Rec’d Date ______________ Deposit ______________
Est. Delivery Cost
__________
be delivered in seven business days,
Ready Date _____________ Balance Due __________
detail reasons here.
Total Pages _____________ Balance Paid __________
Est. Extra Cost
__________
Total Est. Cost
__________
Deposit Amount
__________
Estimated Balance
_________
In Progress
-
Open
__________
Denied
-
Closed __________
________________________ __________________
Filled
-
Closed __________
Custodian Signature
Date
Deposit Date
_________
Partial
-
Closed __________
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