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Sample FOIA Request

COPY this Example to an email body or Word document and fill in ALL the required information.

Contact Information

Title: Mr. Mrs. Ms. Miss First Name, Middle Initial, Last Name

Company Name

Phone Number:
FAX Number:
Email Address:

Full Mailing Address
City, State and Zip Code


Are you representing the interest of another individual? Yes or No

Name of person that you represent:

First-party request means a request by an individual for records pertaining to that individual, or an authorized representative acting on such an individual's behalf.

Fee Category (Type) of requester

Commercial, Non-Commercial Scientific or Educational Institutions, Media or Other Use

Commercial use means a use or purpose that furthers a commercial, trade, or profit interest of the requester or the person or entity on whose behalf the request is made.

Fee category means one of the four categories established by the FOIA to determine whether a requester will be charged fees for search, review, and duplication. The categories are: commercial use requests; non-commercial scientific or educational institutions requests; news media requests; and all other requests. Fee categories are further explained in the Department of Health and Human Services FOIA regulations at §?5.53.


FOIA request means a written request that reasonably describes the records sought.

Please describe the records that you are requesting:

Requested format of responsive records: Paper, Electronic or Other (please describe other)


Please read before selecting: Fee waiver means the waiver or reduction of fees if a requester is able to demonstrate that certain standards set forth in the FOIA and this part are satisfied, including that disclosure of the records is in the public interest because it is likely to contribute significantly to public understanding of the operations or activities of the government and is not primarily in the commercial interest of the requester.

Are you willing to pay fees? Yes or No

Amount you are willing to pay:

Are you requesting a fee waiver? Yes or No

Fee Waiver Justification:

Expedited Processing

Please read before selecting: Expedited processing means the process set forth in the FOIA that allows requesters to request faster processing of their FOIA request, if they can demonstrate a specific compelling need.

Are you requesting expedited processing? Yes or No

Reason for expedited processing: