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2. ONCE COMPLETED & SIGNED RETURN THIS FORM TO MIDLAND CITY ATTORNEY, BY:
   * Hand delivery or regular mail to City Hall, c/o City Attorney, 333 W. Ellsworth Street, Midland, MI 48640
   * Fax to (989) 837-5703
   * Email to: FOIA@midland-mi.org
   * Submit electronically below
4. Date:
   Date:
5. I would like to receive my response by (Check one):*

   1. Mail
   2. Pickup

   1. Fax
   2. Other: _____________

   1. Email
7. First Name
8. Last Name
10. Address1
11. Phone #
13. Address2
14. Fax #
16. City
17. State
18. Email:
20. Zip
22. Complete description of the documents you are requesting -
    be as specific as possible, include date, location, names of parties involved and report number, if available. Failure to sufficiently describe the document may result in a denial of your request pursuant to MCL 15.235(5)(5)(b).
24. **
26. I would like to: *

    (only check one box)

    1. Receive a copy of the requested documents
    2. Review and inspect a copy of the documents

    1. Review the original document
28. I agree and understand that reasonable charges for copy and mailing costs and labor may be incurred.

    Further I:

    1. Request a fee estimate to be provided within 3 business days. I understand that the FOIA coordinator is allowed 5 business days after I receive the fee estimate to provide the requested documents.
    2. Agree to pay the reasonable charges incurred in compiling a response to my request for documents.
30. Non-profit organization documentation or indigence affidavit attached. See MCL 15.234
32. If this is a request for a motor vehicle accident report which was filed with the Midland Police Department, by signing below this request will act as my statement that I acknowledge under MCL 257.503, I (and any organization I might represent) am prohibited from: a) using the report for any direct solicitation of an individual, vehicle owner, or property owner listed in the report and b) disclosing any personal information contained in the report to a third party for commercial solicitation, of an individual, vehicle owner or property owner listed in the report, until thirty (30) days after the date the report is filed. Violation of this law is a misdemeanor, subject to fines and imprisonment.
34. Signature Confirmation*

    1. *

    of my original, handwritten signature when used on this document and creates a legally-binding statement. I further understand that signing this document using my electronic signature will have the same legally-binding effect as signing my signature using pen and paper.
36. First Name*
37. Last Name*
39. Additional Resources:
    * Michigan FOIA: http://www.legislature.mi.gov/
    * City of Midland FOIA Procedures & Guidelines: http://bit.ly/midlandFOIA
Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

* indicates a required field