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2. Date
   Date
4. Village Hall Departments, 2800 Flossmoor Road

   Check the box that applies.

   1. Administration
   2. Police Department
   3. Finance

   1. Planning and Zoning
   2. Fire Department

   1. Building Department
   2. Public Works Department
6. Commercial Purpose?*

   Is this request for a commercial purpose? It is a violation of the Freedom of Information Act to knowingly obtain a public record for a commercial purpose without disclosing that it is for a commercial purpose, if requested to do so by the public body. (5 ILCS 140.3.1 (c)).

   1. Yes

   1. No
8. First Name
9. Last Name
11. Street Number
12. Street Name
13. Street Type
14. Apt #
16. City
17. State
18. ZIP
20. Email Address
21. Phone Number
23. DESCRIPTION OF REQUESTED RECORD(S): Provide as much detail as possible.
25. The Village of Flossmoor will provide documents in the electronic format requested, if feasible.

    Hardcopies: $.15 per page after the first 50 pages for black and white letter or legal. Oversized: actual cost Color copies

27. Chose from the following options:
    -- Select One --Do you want a paper copy of records?Do you want electronic copy of records?
28. Do you want to have copies certified?

    1. Yes
    2. No

    *Charges for certifying a document: $1.00
29. Are you requesting a fee waiver?

    1. Yes
    2. No

    (If you are requesting a fee waiver, you must attach a statement of the purpose of the request, and whether the principle purpose of the request is to access or disseminate information regarding the health, safety and welfare or legal rights of the general public. 5 ILCS 140/6C))
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31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field