File: KBA-F1 CAMPBELL COUNTY SCHOOL BOARD REQUEST

File: KBA-F1

CAMPBELL COUNTY SCHOOL BOARD

REQUEST FOR PUBLIC RECORDS

Name _________________________________

STAFF USE ONLY

Date Request Received:__________

Request was made (check one)

 by requester on this form

 by telephone

 in writing other than on form

(attach original request)

Date Response Sent: ____________

(attach copy)

 Identification Verified

Type: ________________________

Number: ______________________

 Itemized Cost Estimate Attached

Address ______________________________

_____________________________________

E-mail address _________________________

Phone _________________________________

I am a (check one):

 Citizen of the Commonwealth of Virginia

 Member of the Press referenced in Va. Code

§2.2-3704

News Organization ____________________

Requesters may be asked to provide verification

that they are citizens of the Commonwealth or a

member of the press referenced in Va. Code

§ 2.2-3704.

I am requesting access to the following records (please be as specific as possible, and

attach additional paper if necessary _______________________________________________

Reasonable costs may be assessed in connection with this request. A current schedule

of costs appears in Regulation KBA-R Requests for Public Records. If the costs associated with

this request are expected to exceed $200, the requestor will be asked to pay the estimated

costs before the request is processed.

In addition, the requestor may ask for an advance determination of the cost of the

request. Please indicate here if you would like an advance determination of cost.

Yes ___ No ___

If you are requesting copies, please specify the format in which you would like to receive

them. BLANK school division will provide the record(s) in the requested format if that medium is

used by it in the regular course of its business.

Specify format desired (if available):

 Photocopies

 E-mail (give address): ___________________

 Website posting

 Other (please specify):

___________________

________________________________ ______________________

Signature Date

RETURN COMPLETED FORM TO:

CAMPBELL COUNTY PUBLIC SCHOOLS

Mrs. Amy Hunley, FOIA Officer

P. O. Box 99

Rustburg, VA 24588