State of Illinois Liquor Control Commission Governor Pat Quinn  Acting Chairman Stephen Schnorf FREEDOM OF INFORMATION ACT REQUEST Contact: Illinois Department of Revenue FOIA Officer Tel: (217) 782-0985  Fax: (217) 524-3402 ___________________________________________ Requestor’s Name, Firm or Other Affiliation ___________________________________________ Requestor’s Street Address ___________________________________________ City, State, Zip Code ___________________________________________ Telephone (Including area code) Business Organization or Status : ___ Private, For-Profit, Commercial ___ Private, Not-For-Profit ___ Media ___ Student, Researcher ___ Industry Association ___ Attorney, Litigants ___ Unit of Local, National Government ___ Other State Agencies (For official use only) ___________________________________________ Requestor’s Signature and Date of Request DESCRIPTION OF INFORMATION REQUESTED: (If requesting license information, please indicate if you require a copy of the license, including the valid date required, or the license application.) ___ Copies ___ Inspect Documents ___ Special Request (Must use attached data request form) REASON FOR REQUEST: APPROVED: DENIED: DEFERRED: _____ _____ _____ _____ Requested information is enclosed. Information will be produced upon receipt of payment of $_________. Information may be inspected at this office on _____________, 20__. Request creates an undue burden on a public body in accordance with §3(f) of the Illinois Freedom of Information Act, and this office was not able to negotiate a more reasonable request. _____ Information requested are exempt under §7___ of the Illinois Freedom of Information Act for the Following Reasons:_____________________________. _____ In accordance with §3(d) of the Illinois Freedom of Information Act, the request is delayed for the following reasons: __________________________________. You will be notified by __________, 20__, as to the action taken on the request. RIGHT OF APPEAL: If desired, submit a copy of the denied request along with a written statement of reasons in support as your appeal of the forgoing decision to: Brian Hamer, Director, Illinois Department of Revenue, 101 West Jefferson Street, Springfield, Illinois 62702. __________________________________________ George Logan, Acting IDOR FOIA Officer _______________________________ Date of Reply Mail to: Illinois Department of Revenue, 101 W Jefferson Street, MC 6-595, Springfield, IL 62702 American LegalNet, Inc. www.FormsWorkFlow.com