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2. Name of Public Body Receiving Request*

   1. Village of Roselle
   2. Roselle Police Department
4. Date Requested*
   Date Requested
6. First Name*
7. Last Name*
9. Address1
11. Address2
13. City*
14. State*
15. Zip*
17. Phone Number
18. E-Mail
20. Fax Number
22. Records Requested*
    Provide as much specific detail as possible so the public body can identify the information that you are seeking.
24. Do you want copies of the documents?*

    1. Yes
    2. No
26. If you are requesting documents, do you want:

    1. Electronic Copies?
    2. Paper Copies?
27. If you want electronic copies, in what format?
29. Is this request for a commercial purpose?*

    1. Yes
    2. No

    (It is a violation of the Freedom of Information Act for a person 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)).
30. Are you requesting a fee waiver?

    1. Yes
    2. No

    (If you are requesting that the public body waive any fees for copying the documents, you must attach a statement of the purpose of the request, and whether the principal 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 140/6(c)).
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32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field