REQUEST FOR RECORD INSPECTION OR FOR A COPY (The section below is to be completed by person making the request) Date: Name: Address: Daytime Phone: Fax: ___________________________________ I certify that I do not intend to, and will not: (1) Use any list of names or addresses contained in or derived from the records or information requested for the purpose of selling or offering for sale any property or service to any person listed or to any person who resides at any address listed; or (2) sell, give, or otherwise make available to any person any list of names or addresses contained in or derived from the records or information for the purpose of allowing that person to sell or offer for sale any property or service to any person listed or to any person who resides at any address listed. See K.S.A. 45-230. Signature: __________________________________________________________________ RECORD SOUGHT: Please provide as specific a description as possible of the records you desire to inspect or for which you request a copy. Include records titles and dates as well as the name of the court which holds the record. Description of Record # of copies desired 1. ________________________________________________________________________ 2. ________________________________________________________________________ 3. ________________________________________________________________________ CHARGES: A charge for providing access to public records is authorized by state law and has been established by the Kansas Supreme Court. Charges are set to compensate for the actual costs in honoring your request. The fee schedule established for this Judicial District is posted in the office of the Clerk of the District Court. The charge for access to and/or copies of the record(s) you have requested is estimated to be $ ___________________. Prepayment of the above amount may be required. American LegalNet, Inc. www.FormsWorkflow.com (The section below is to be completed by the Record Custodian) Time of request: ________________________________________________________________ (Date) (Time) (Person receiving request) Records Provided or Denied: ______________________________________________________ (Date) (Time) (Person providing record or denial) Staff time involved: ___ hours, ___ minutes, for a charge of $ _________________________. Charge for copies made: $ ___________________ Total Charges: $ ___________________ Estimated payment received $ ___________________ Amount remaining due $ ___________________ (or) Amount refunded $ ___________________ ______________________________________ Record Custodian (9/00) American LegalNet, Inc. www.FormsWorkflow.com