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Public Records Request and Fee Reduction/Waiver Form

2. I. Contact Information

   Please provide any information necessary to fulfill and deliver your request. At least one method of communication is required.

   Please provide any information necessary to fulfill and deliver your request. At least one method of communication is required.

4. First Name

5. Last Name

7. Organization (if applicable)

8. Email Address

10. Address1

12. Address2

14. City

15. State

16. Zip

18. Telephone Number

19. Fax Number

21. Are you a convicted felon?

    1. Yes
    2. No

25. II. Request Description

    Describe the records requested. Be as specific as possible, using names, dates, locations, departments, etc. Please attach additional sheets as necessary.

    Describe the records requested. Be as specific as possible, using names, dates, locations, departments, etc. Please attach additional sheets as necessary.

27. Description of Requested Records*

31. III. Delivery Preference

    Please check all that apply.

    Please check all that apply.

33. Delivery Options

    1. View duplicate and/or original records at the Shreve Memorial Library Administrative Offices during normal business hours at no cost.
    2. Pick up duplicate(s) during normal business hours at the cost outlined in the fee schedule.
    3. Receive duplicate(s) via mail and/or fax at the cost outlined in the fee schedule.
    4. Receive duplicate(s) via email, understanding that some records will not be available for email transmission.
    5. Receive duplicate(s) via Dropbox and/or website, understanding that some records will not be available for electronic transmission.

37. IV. Fee Waiver/Reduction

    Please check all that apply. Local, City, or Parish entities may qualify for fee reduction, but do not qualify for fee waivers.

    Please check all that apply. Local, City, or Parish entities may qualify for fee reduction, but do not qualify for fee waivers.

39. Fee Reduction Certification

    1. I am a citizen of the State of Louisiana who is indigent and lacks the means to pay $0.25 per single-sided black and white copy.
    2. The use of copies requested is limited to a public purpose (including, but not limited to, use in a hearing before any government regulatory commission).

41. Reduction Condition

    1. The information is not to be used for personal or proprietary use.
    2. If, in the future, the Shreve Memorial Library determines my use of these documents to be different than represented here, the Library reserves the right to recover costs for duplication.

43. Fee Waiver Certification

    1. The copies requested are solely for use by the Federal Agency named above under "Organization."
    2. The copies requested are solely for use by the Louisiana State Government Agency named above under "Organization."

Leave This Blank:


46. 1. Receive email copy
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field