Shandaken Police Department

Application for Record, Article 6 Public Officers Law Freedom of

Identify the type of record(s) requested.
Be as specific
Information
Act as possible. Advance payment (see
below) is required in cash, certified check or money order payable to SHANDAKEN POLICE DEPARTMENT
prior to records release. Include an address or telephone number where you can be contacted.
Send the completed application to the Records Access Officer at PO Box 134 Shandaken, New York
12480

APPLICATION FOR COPIES OF

_____________________________________________________________________________________
Date: _______________ Time: __________ Type of Incident: __________________________________
Person(s) Involved: ______________________________________________________________________
I hereby apply to INSPECT / PURCHASE copies of the described records
Name: __________________________________________________
Firm: ___________________________________________________
Address: ______________________________________________________________________________
Signature: _____________________________________________________________________________
____________ Your request for records is hereby acknowledged. A short period of time is necessary to research
the existence of, and or review, the record(s) you have requested. You will be contacted at the telephone number
or address you have provided concerning availability and/or associated costs.
________________________________________________ Date: _____________________________
(Members Name)
DISPOSITION OF REQUEST
__ Remit amount indicated below to Records Access Officer Shandaken Police Department, PO Box 134 Shandaken,
New York 12480
__ DENIED for reason(s) checked References are to sec. 87 of the Public Officers Law.
__ Exempt Law Enforcement (2.(e))

__ Inter/Intra-agency material (2.(g))

__ Other ______________________________________________________
__ UNAVAILABLE for reasons checked
__ Not described in sufficient detail

__ Not maintained by this Office

__ Other __________________________________________________
Signed: ________________________________ Date: _______________
Schedule of fees:
Charges for Copying:
Pages up to 9 x 14 - 25 ea.
Pages over 9 x 14 70 ea.
Other:
Photographs Cost to reproduce
Video Cassette - $25.00 ea.
Audio Cassette - $15.00 ea.

Charges for material supplied under FOIL

Type of Material Number
Price Per Item
Total
____________ ______ __________
_________
____________ ______ __________
_________
____________ ______ _________
_________
Received ________________________

$ _________