Request to Inspect Public Records

Pursuant to the Kentucky Open Records Act (“the Act”), KRS 61.870 et seq., the undersigned
requests to inspect the public records which are described below.

Requester's Contact Information

Name *

Mailing Address *

Street Address *

Address Line 2

City *

State / Region / Province *

Postal / Zip Code *

E-mail Address (If Applicable)

Records to be inspected *

Describe the public records You wish to inspect *

Statement regarding the use of public records.

KRS 61.870(4) defines “commercial purpose” as “the direct or indirect use of any part of a public
record or records, in any form, for sale, resale, solicitation, rent, or lease of a service, or any use
by which the user expects a profit either through commission, salary, or fee.” However,
“commercial purpose” does not include the publication or related use of the public record by a
newspaper or periodical, by a radio or television station in its news or informational program,
or by use in the prosecution defense of litigation by the parties to such an action or their attorney.

This request is: *

NOT for a commercial purpose; orFOR a commercial purposeThird Choice

(Choose one)

Statement regarding residency

I further state that I am a resident of Kentucky because I am: *

An individual residing in the Commonwealth; orA domestic business entity with a location in the Commonwealth; orA foreign business entity registered with the Kentucky Secretary of State; orAn individual that is employed and works at a location within the Commonwealth; orAn individual or business entity that owns real property within the Commonwealth; orAn individual or business entity that has been authorized to act on behalf of an individual or business entity listed above; orA news-gathering organization as defined in KRS 189.635(8)b1a to e

Please check one.

Signature *

Date *

Pursuant to KRS 61.876(4), the Office of Attorney General has promulgated by administrative
regulation this form. See 40 KAR 1:040.