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4. FREEDOM OF INFORMATION ACT REQUEST FOR RECORDS FORM
8. Requestor's Information
10. Name*
11. Email Address*
13. Address*
15. City*
16. State*
17. Zip Code*
19. Phone Number*
20. Fax Number
24. Requested Information
26. Please specify below the specific records which you are requesting, including Tax Map and Parcel numbers for land records.
28. Note: that FOIA requests are only for existing information.*

30. By submitting this request I am aware that State Law allows the County of Louisa five (5) business days to respond to a request for information. The County of Louisa is allowed to charge me for the cost of accessing, searching, supplying and duplicating requested records. If the charge for providing the requested records is likely to exceed $200, I will be required to pay a deposit in advance up to this amount. 

    Costs may include: 

    • Printed copies @ .50 cents per page,
    • Hourly staff pay rate, 
    • Standard USPS postage rate 
    • $2 for CD disc.

    In conformance with the authority provided by (Va. Code §2.2-3704(F)), it is the policy of the County of Louisa to recover the costs of accessing, duplicating, supplying, or searching for records.

32. I agree to pay this cost but wish to receive an estimate of the cost first if it exceeds:*
36. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
38. Electronic Signature*
39. Date*
    Date
Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit Submit and Print

* indicates a required field