FOIA Requests – Western UP Health Department

Original Name of Owner *

(Person who applied for permits)

Other Property Owner Names *

(Contact County Equalization Office to obtain information)

Location Address *

County *

Township *

Section / T_N / R_W *

Parcel ID Number *

Information Requested *

Checkboxes *

I understand I will be required to pay a fee for producing and duplicating records, calculated as follows:1) Actual mailing cost 2) Incremental costs of duplication or publication, to include: The cost of labor incurred in duplication, mailing, search, review, examination, and separation. The cost will be based on the hourly wage of the lowest paid employee who is capable of retrieving the information, multiplied by the time spent. 3) Actual copy/scanned cost multiplied by the number of pages, calculated at $.10 per page. An invoice detailing the above components will be sent with the records requested. Exempt from the above fees are requests by: • Health care providers who continue care or treatment for our clients • Federal, State, or County authorities, as allowed by law • Medicare I understand the WUPHD has ten (10) days to comply with this request. Please notify me immediately of any decision not to comply and the reasons thereof.

Requestor's Name *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *