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2. Name of Requesting Party:*
4. Address1*
6. Address2
8. City
9. State
10. Zip
12. Email of Requesting Party*
14. Phone Number of Requesting Party*
16. Records Requested. Please be Specific*
18. Check one: I request to receive my records by*

    1. In person, pick up
    2. Regular Mail
    3. Email
Leave This Blank:


20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit

* indicates a required field