# of Copies: _______

Morgan County Health Department

Request for Disclosure of Public Records

1. Name: ___________________________________________________________

(Last) (First) (Middle)

2. Address: __________________________________________________________

(Street Address) (City)

__________________________________________________________

(State) (Zip Code)

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3. Date of Request: _______________ 4. Time of Request: __________PM

5. Please identify the record(s) you wish to view or copy. Your description should be as specific as possible, in order to expedite location of the record(s).

6. Please state, if you wish, the reason that you want to view this record. (Optional)

7. Do you want the record copied? Yes ____ No ____

8. Signature ___________________________________

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1. Request Received: ___________________________________________________PM

(Date) (Time)

2. Name of person receiving the request: _______________________________________

3. Disposition of request: Granted: _______ Denied: _______

4. If request was denied, state reasons for denial:

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5. Date and Time of Disposition: __________________________________________PM

(Date) (Time)