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One Park Center Ct. Suite A Manassas Park VA 20111

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File: KBA-F1


Download Form

Name _______________________________________________
Address _____________________________________________
E-mail address ______________________________________
Phone _______________________________________________
I am a (check one):
___ Citizen of the Commonwealth of Virginia
___ Member of the Press referenced in VA Code §2.2-3704
News Organization _______________________________________

Requesters may be asked to provide verification
that they are citizens of the Commonwealth or a
member of the press referenced in Va. Code § 2.2-3704.


Date Request Received ______________
Request was made (check one):
___ requester on this form
___ telephone
___ in writing other than on form
(attach original request)
Date Response Sent: ______________
(attach copy)
___ Identification verified
Type: ____________________________
Number: ________________________

__ Itemized Cost Estimate Attached

I am requesting access to the following records (please be as specific as possible, and attach additional paper if necessary _______________________________________________

Reasonable costs may be assessed in connection with this request. A current schedule of costs appears in Regulation KBA-R Requests for Public Records. If the costs associated with this request are expected to exceed $200, the requestor will be asked to pay the estimated costs before the request is processed.

In addition, the requestor may ask for an advance determination of the cost of the request. Please indicate here if you would like an advance determination of cost.

Yes ___ No ___

If you are requesting copies, please specify the format in which you would like to receive them. Manassas Park City school division will provide the record(s) in the requested format if that medium is used by it in the regular course of its business.

Specify format desired (if available):

___ Photocopies
___ E-mail (Give address) __________________________________________
___ Website posting
___ Other (please specify) _________________________________________

Signature: _________________________________________________________

Date: ______________________________________________________________

Manassas Park City Schools
1 Park Center Court, Suite A
Manassas Park, VA 20111

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