Centre Cnty. C.P. Rule 509 Request Form

Please submit this form to the appropriate UJS records manager. Contact information may be found on the UJS

website under "Financial Records" at http://www.aopc.org/T/AOPC/PublicAccessPolicy.htm

RULE 509 REQUEST FORM

Please Type or Print in Black or Blue Ink

Name of

Requestor Last First Middle

Signature Date

Mailing

Address Street / PO Box

City State Zip Code

Telephone Fax

Number Number

Email Address

Please identify each of the documents that are requested. It is important that your request be as specific as

possible so that we may determine whether we have these documents.

Note: Information related to standard fees and procedures may be found on AOPC's website

http://www.aopc.org/T/AOPC/PublicAccessPolicy.htm or relevant local court's website. Additional fees may be levied

as necessary to cover costs incurred in fulfilling specific information requests. Pre-payment will be required if

expected compliance costs exceed $100.

Official Use Only CHARGE Comments

Date Received

Tracking Number (if applicable)

Total Cost