Public Records Act Request Form

This form is provided for your convenience but is not required to request records. Providing contact information will allow us to reach you in the event we require additional information to fulfill your request.

Section A – Contact Information

First Name

Last Name

Company Name (if any)

Street

Apartment/Suite

City

State

Zip

Phone

Section B - Record(s) Requested

Describe the information you are requesting. Be specific as possible and include enough detail to assist us in locating the record(s)


Section C - Additional Information Providing the information in Section C is voluntary.

Is this information being requested for pending or anticipated litigation in which State Fund may be a party?	Yes	No

Is this request for media purposes?	Yes	No


Section D - For State Fund Use Only
Employee First Name
Employee Last Name
Regional Office/Program


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