Date Request Is Made:

Request Submitted By (check one of the following) -

E-MAIL U.S. MAIL FAX IN-PERSON

Name Of Requestor -

Street Address -

City -

State -

Zip -

County -

Telephone (Optional) -

Records Requested -
—— Provide as much specific detail about Requested Records so the Township can identify the information——

Do You Want Copies? (check one of the following) -

YES NO

Do You Want To Inspect The Records? (check one of the following) -

YES NO

Do You Want Certified Copies Of Records? (check one of the following) -

YES NO

Right to Know Officer - VICKY ROTH — Alternate — SANDRA PUDLINER

TOWNSHIP OFFICER WILL ENTER THE DATES BELOW:

Date Received By The Agency - ____________________________

Agency Five (5-Day) Response Due - ________________________

Contact Info for Appeals Officer
Terry Mutchler — Executive Director — Officer of Open Records
Commonwealth Keystone Bldg. — 400 North St., 4th Floor — Harrisburg, PA 17120

Public bodies may fill anonymous verbal or written requests. If the requestor wishes to pursue the
relief and remedies provided for in this Act, the request must be in writing. Written requests need
not include an explanation why information is sought or the intended use of the information unless
otherwise required by law.

Hanover Township — Lehigh County
2202 Grove Road — Allentown, PA 18109
610.264.1069 — 610.266.9292 — 610.264.2773

EXHIBIT “A”

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