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3. Request for

   1. Certified copy
   2. Copy

   1. Record inspection
   2. Subscription to record issued on regular basis
5. Name
6. Email Address
8. Firm / Organization
9. Address
11. City
12. State
13. Zip Code
15. Phone Number
16. Fax Number
18. Delivery Method

    1. Deliver on digital media provided by the City
    2. Email to requestor

    1. Mail to requestor's address
    2. Will pick up
20. Deliver on digital media provided by the City
22. Note: The City is not required to provide records in a digital format if the City does not already have the technological capability to do so.
24. Describe the public record(s) as specifically as possible.
26. Acknowledgements
    1. I hereby acknowledge that, the City of Charlevoix will charge me a fee for locating, copying and mailing the requested public records. I may be eligible for an indigent or non-profit discount with the proper documentation. I agree to pay the fees charged by the City no later than seven days after receiving the requested public records.
    
    2.I further acknowledge that if the estimated fee is greater than $50, the City of Charlevoix may require that I pay a deposit of no more than 50% of the estimated fees prior to the City processing my request. If a deposit is required, I agree to pay the balance of the fees due within seven days after receiving the requested public records.
    
    3. Finally, I acknowledge that under the Freedom of Information Act this request must be kept on file for no less than one year from the date submitted. As a result, this written request will itself become a public record, subject to disclosure under the Act.
28. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
30. Electronic Signature
31. Date
    Date
33. Consent to Non-Statutory Extension of City’s Response Time
    I have requested a copy of records or a subscription to records or the opportunity to inspect records, pursuant to the Michigan Freedom of Information Act, Public Act 442 of 1976, MCL 15.231, et seq. I understand that the City must respond to this request within five business days after receiving it, and that response may include taking a 10-business day extension.
35. However, I hereby agree and stipulate to extend the City's response time for this request until:
    However, I hereby agree and stipulate to extend the City's response time for this request until:
37. Records Located on City Website
    Any public records available to the general public on the City’s website at the time of the request are exempt from any labor charges to redact (separate exempt information from non-exempt information).
    
    If the FOIA coordinator knows that all or a portion of the requested information is available on its website, the City must notify the requestor in its written response that all or a portion of the requested information is available on its website. The written response, to the degree practicable in the specific instance, must include a specific webpage address where the requested information is available.
    
    On the detailed cost itemization form, the City must separate the requested public records that are available on its website from those that are not available on the website and must inform the requestor of the additional charge to receive copies of the public records that are available on its website.
    
    If the requestor thereafter stipulates that the public record be provided to him or her in a paper format or other form, including digital media, the City will provide the public records in the specified format (if the City has the technological capability) and applicable fees will be charged.
    
    I hereby stipulate that, even if some or all of the records are located on a City website, I am requesting that the City make copies of those records on the website and deliver them to me in the format I have requested above. I understand that some FOIA fees may apply.
39. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
41. Requestor's Electronic Signature
42. Date
    Date
44. Overtime Labor Costs
    Overtime wages shall not be included in the calculation of labor costs unless overtime is specifically stipulated by the requestor and clearly noted on the detailed cost itemization form.
46. I hereby agree and stipulate to the City using overtime wages in calculating the following labor costs as itemized in the following categories:

    1. Labor to locate / examine

    1. Labor to redact

    1. Labor to copy / duplicate
48. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
50. Requestor's Electronic Signature
51. Date
    Date
53. Request for Discount: Indigence
    A public record search must be made and a copy of a public record must be furnished without charge for the first $20 of the fee for each request by an individual who is entitled to information under this act and who:
    1) Submits an affidavit stating that the individual is indigent and receiving specific public assistance, or
    2) If not receiving public assistance, stating facts showing inability to pay t he cost because of indigence.
    If a requestor is ineligible for the discount, the public body shall inform the requestor specifically of the reason for ineligibility in the public body's written response. An individual is ineligible for this fee reduction if any of the following apply:
    (i) The individual has previously received discounted copies of public records from the same public body twice during that calendar year,
    (ii) The individual requests the information in conjunction with outside parties who a re offering or providing payment or other remuneration to the individual to make the request. A public body may require a statement by the requestor in the affidavit that the request is not being made in conjunction with outside parties in exchange for payment or other remuneration.
    
    I am submitting an affidavit and requesting that I receive the discount for indigence for this FOIA request.
55. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
57. Requestor's Electronic Signature
58. Date
    Date
61. Request for Discount: Nonprofit Organization
    A public record search must be made and a copy of a public record must be furnished without charge for the first $20 of the fee for each request by a nonprofit organization formally designate d by the state to carry out activities under subtitle C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 and the Protection and Advocacy for Individuals with Mental Illness Act, if the request meets all of the following requirements:
    (i) Is made directly on behalf of the organization or its clients.
    (ii) Is made for a reason wholly consistent with the mission and provisions of those laws under section 931 of the Mental Health Code, 1974 PA 258, MCL 330.1931.
    (iii) Is accompanied by documentation of its designation by the state, if requested by the City.
    
    I stipulate that I am a designated agent for the nonprofit organization making this FOIA request and that this request is made directly on behalf of the organization or its clients and is made for a reason wholly consistent with the mission and provisions of those laws under section 931 of the Mental Health Code, 1974 PA 258, MCL 330.1931.
63. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
65. Requestor's Electronic Signature
66. Date
    Date
Leave This Blank:


69. 1. Receive an email copy of this form.
70. Email address

    This field is not part of the form submission.

71. Submit

* indicates a required field