HomeMy WebLinkAboutFOIL REQUEST FORMELIZABETH A. NEVILLE TOWN HALL, 53095 MAIN ROAD
TOWN CLERK P.O. BOX 1179
REGISTRAR OF VITAL STATISTICS SOUTHOLD NY 11971
MARRIAGE OFFICER FAX: 631-765-.6145
RECORDS MANAGEMENT OFFICER TELEPHONE: 631-765-1800
FREEDOM OF INFORMATION OFFICER southoldtown.northfork.net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
APPLICATION FOR PUBLIC ACCESS TO RECORDS
INSTRUCTIONS
: Please complete section I of this form and give to Town Clerk’s Office (agency
Freedom of Information Officer). One copy will be returned to you in response to your request, or as
an interim response.
?????????????????????????????????????????????????????????????????????????
SECTION I.
TO:
_______________________________________________________________________________
(Department or Officer, if known, that has the information you are requesting).
RECORD YOU WISH TO INSPECT:
(Describe the record sought. If possible, supply date, file
title, tax map number, and any other pertinent information).
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Signature of Applicant: ________________________________________________________________
Printed Name: _______________________________________________________________________
Address: ___________________________________________________________________________
Mailing Address (if different from above): ________________________________________________
Telephone Number: ____________________________________ Date: _________________________
[ ] APPROVED [ ] DENIED*
[ ] APPROVED WITH DELAY*
_____________________________________ ______________________________________
Elizabeth A. Neville Date
Freedom of Information Officer Hand carry to department?
Accepting Clerk’s Initials ____ Yes_____ No_____ Applicant’s initials_____
*If delayed or denied, see reverse side for explanation.
SECTION II:
(For use by Freedom of Information Officer only).
DENIED
Your request has been for the reason(s) check below:
[ ] Confidential Disclosure
[ ] Part of Investigatory Files
[ ] Unwarranted Invasion of Privacy
[ ] Record of which this agency is legal custodian, but cannot be found
[ ] Exempted by Statute other than the Freedom of Information Act
[ ] Other (specify): ________________________________________________________________
_____________________________________________________________________________
ACKNOWLEDGED
Your request is . There will be a delay in supplying the requested record until:
___________________________________________________________________________________
Reason for delay: ____________________________________________________________________
?
?????????????????????????????????????????????????????????????????????????
SECTION III. RIGHT TO APPEAL
YOU HAVE A RIGHT TO APPEAL A DENIAL OF THIS APPLICATION IN WRITING
WITHIN 30 DAYS OF THE DENIAL. CONTACT THE SOUTHOLD TOWN BOARD (see
below). THE TOWN BOARD MUST RESPOND TO YOU IN WRITING WITHIN TEN
BUSINESS DAYS OF RECEIPT OF YOUR APPEAL.
Southold Town Board
Southold Town Hall
53095 Main Road, P O Box 1179
Southold NY 11971
Telephone: 631-765-1800
?
?????????????????????????????????????????????????????????????????????????