Public Records Request Form – Pearl River County Library System

I. Contact Information

Please provide any information necessary to fulfill and deliver your request. At least one method of communication is required.

Name(Required)

First Last

Organization (if applicable)

Email Address(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Telephone Number(Required)

Fax Number

Are you a convicted felon?(Required)

Yes

II. Request Description

Describe the records requested. Be as specific as possible, using names, dates, locations, departments, etc. Please attach additional sheets as necessary.

Description of Requested Records(Required)

III. Delivery Preference

Please check all that apply.

Delivery Options

View duplicate and/or original records at the Pearl River County Library System Headquarters during normal business hours at no cost.

Pick up duplicate(s) during normal business hours at the cost outlined in the fee schedule.

Receive duplicate(s) via mail and/or fax at the cost outlined in the fee schedule.

Receive duplicate(s) via email, understanding that some records will not be available for email transmission.

Receive duplicate(s) via Dropbox and/or website, understanding that some records will not be available for electronic transmission.

IV. Fee Waiver/Reduction

Please check all that apply. Local, City, or County entities may qualify for fee reduction, but do not qualify for fee waivers.

Fee Reduction Certification

I am a citizen of the State of Mississippi who is indigent and lacks the means to pay $0.25 per single-sided black and white copy.

The use of copies requested is limited to a public purpose (including, but not limited to, use in a hearing before any government regulatory commission).

Fee Waiver Certification

The copies requested are solely for use by the Federal Agency named above under "Organization."

The copies requested are solely for use by the Mississippi State Government Agency named above under "Organization."

Receive a copy of this form.

Yes

Email(Required)

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