REQUEST FORM

MONTGOMERY COUNTY HOUSING AUTHORITY

104 West Main Street, Suite 1
Norristown, PA 19401
(610) 275-5720

DATE REQUESTED:

REQUEST SUBMITTED BY:           E-MAIL            U.S. MAIL       FAX     IN-PERSON

NAME OF REQUESTOR :__________________________________________________

STREET ADDRESS         :__________________________________________________

CITY/STATE/COUNTY(Required): __________________________________________

TELEPHONE (Optional):___________________________________________________

RECORDS REQUESTED:

*Provide as much specific detail as possible so the MCHA can identify the information.

DO YOU WANT COPIES?  YES or NO

DO YOU WANT TO INSPECT THE RECORDS?  YES or NO

DO YOU WANT CERTIFIED COPIES OF RECORDS? YES or NO

______________________________________________________________________

TO BE COMPLETED BY MCHA

RIGHT TO KNOW OFFICER:

DATE RECEIVED BY THE MCHA:

AGENCY FIVE (5)-DAY RESPONSE DUE:

In lieu of this form, the Commonwealth's Office of Open Records form may also be used.