Request For Public Record Form Indiana Access to Public Records Act - Indiana Code 5-14-3 ET SEQName of Requesting Party* Company if applicableAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* PhoneRecord Requested*Please Identify with reasonable particularly the record being requestedRequests for List of Names Address: Pursuant to Indiana Code 5-14-3-3(f), lists of names and addresses may not be disclosed to any individual or entity for political purposes or to commercial entities for commercial purposes. If the record being requested is a list of names and addresses, the Affidavit of Noncommercial and Nonpolitical Use must be completed and returned with this form.
