Public Records Request

2. Date of Request*
   Date of Request

3. Subject of Request*

5. Name

6. Email Address

8. Address

10. City

11. State

12. Zip Code

14. Phone Number

15. Fax Number

17. Information Requested*

    Please identify the documents/records being requested. Please be as specific as possible. The more specific your request, the better City staff can locate and retrieve the information in a timely manner.

19. Receiving Public Documents*
    -- Select One --I will pick up copies at the designated City office.I wish to review the information only; no copies necessary at this time.Call the phone number listed above to notify me when information is available.Mail copies to the mailing address listed above.Email copies to the email address listed above (as practical).Fax copies to the fax number listed above (as practical).I will call the City (937-333-3616) to determine when records are available.

    How would you like to receive the information you are requesting?

21. Cost*

    The cost to obtain documents through a public information request is $.10 cents per impression plus the actual cost of the medium in which the information is provided (i.e., CD, DVD, videotape, audiotape, etc.). Unless otherwise agreed, payment is due before the documents are provided. Checks should be made payable to the City of Dayton.

    1. I understand there is a cost for receiving public records.
Leave This Blank:


23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit Submit and Print

* indicates a required field