Section 726.APPENDIX A Request for Public Records

TO: Freedom of Information Officer Illinois Department on Aging 421 East Capitol Avenue Springfield, Illinois 62706	FROM:
		NAME
		ADDRESS

		PHONE NUMBER

DESCRIPTION OF REQUESTED RECORD(S):

Please indicate if you wish to inspect the above captioned records or wish a copy of them:

	Inspection	Copy		Both
Do you wish to have copies certified?

FOR OFFICE USE ONLY:
Date Received			Date Response Due

Notations re Oral Communications or Other Items: