"Requesters Public Records Request/Report Information" - Mississippi

Requesters Public Records Request/Report Information is a legal document that was released by the Mississippi Department of Education - a government authority operating within Mississippi.

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Office of Public Reporting
PO Box 771
Jackson, MS 39205-0771
601-359-3857
Email: reporting@mdek12.org
Requesters Public Records Request/Report Information
Full Name:
____________________________________________________________________________
Last
First
M.I.
Organization:
____________________________________________________________________________
Address:
____________________________________________________________________________
Street Address
____________________________________________________________________________
City
State
Zip Code
Phone:
________________________________ Alternate Phone: _____________________________
Email:
____________________________________________________________________________
Information Requesting
I hereby request the following records maintained by the MS Department of Education. (Request shall
be specific enough to allow the Department employees to identify and retrieve records requested)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
My Request is to:
_____ 1. Review the records listed above
_____ 2. Receive copy (s) of records listed above
_____ 3. Mail copy (s) of records to address shown above
I understand that appropriate charges for searching, copying and/or mailing shall be paid in full prior to
granting this request. I acknowledge that the Mississippi Department of Education has a minimum of
seven (7) working days from the date of receipt to respond to my request in accordance with MS Public
Records Act § 25-61-1 seq.
Signature of person making request:
____________________________________________________
____________________________________________________
Title
Date
MDE USE ONLY
Footprint Number: ___________________
Date Completed:_____________________________
Approved
Denied
Office of Public Reporting:
Initials__________ Date_____________
Legal:
Initials__________ Date_____________
Cost: $_____________________
Date Payment Received:______________________________
Office of Public Reporting
PO Box 771
Jackson, MS 39205-0771
601-359-3857
Email: reporting@mdek12.org
Requesters Public Records Request/Report Information
Full Name:
____________________________________________________________________________
Last
First
M.I.
Organization:
____________________________________________________________________________
Address:
____________________________________________________________________________
Street Address
____________________________________________________________________________
City
State
Zip Code
Phone:
________________________________ Alternate Phone: _____________________________
Email:
____________________________________________________________________________
Information Requesting
I hereby request the following records maintained by the MS Department of Education. (Request shall
be specific enough to allow the Department employees to identify and retrieve records requested)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
My Request is to:
_____ 1. Review the records listed above
_____ 2. Receive copy (s) of records listed above
_____ 3. Mail copy (s) of records to address shown above
I understand that appropriate charges for searching, copying and/or mailing shall be paid in full prior to
granting this request. I acknowledge that the Mississippi Department of Education has a minimum of
seven (7) working days from the date of receipt to respond to my request in accordance with MS Public
Records Act § 25-61-1 seq.
Signature of person making request:
____________________________________________________
____________________________________________________
Title
Date
MDE USE ONLY
Footprint Number: ___________________
Date Completed:_____________________________
Approved
Denied
Office of Public Reporting:
Initials__________ Date_____________
Legal:
Initials__________ Date_____________
Cost: $_____________________
Date Payment Received:______________________________