APPLICATION FOR PUBLIC ACCESS TO RECORDS

TOWN OF ULYSSES

Mail To:   Marsha L. Georgia

                Records Management Office

               10 Elm St.

               Trumansburg, NY 14886

   Office # 607-387-5767 FAX 607-387-5843

FROM:  Name ________________________________

                Address ________________________________

I HEREBY APPLY TO INSPECT THE FOLLOWING RECORD: 

 ________________________________________________________________

COPIES ARE $.25 PER PAGE

____________________________________________________________________________________________________________

FOR AGENCY USE ONLY

APPROVED ____

 DENIED (FOR REASON (S) CHECKED BELOW)

____Confidential Disclosure           ____Part of Investigatory files

____Unwarranted Invasion of Personal Privacy

____Record of which this Agency is Legal Custodian cannot be found

____Record is not maintained by This Agency

____Exempted by Statute Other Than the Freedom of Information Act

____Other (specify) ________________________________________

Signature: ________________________________ Title: __________________________ Date: _____________________

Notice: You have a right to appeal a denial of this application to the Head of this Agency

 Who must fully explain reasons for such denial in writing seven days of receipt of an appeal?

I hereby appeal:

Signature:______________________________________ Date: __________________________