Form Center

2. Office of Village Clerk Kristy Merrill
   2121 W Lake Street
   Hanover Park, IL 60133
   Phone: 630-823-5602
   Fax: 630-823-5786
4. Record Request Form
   If you do not use this form for requests for inspecting or copying of Public Records pursuant to the Freedom of Information Act, you must provide your request in writing. For Requests for Fire Department Medical Reports & Billing, please contact: Andres Medical Billing 3323 N. Ridge Avenue Arlington Heights, Illinois 60004 1-847-577-8811
6. Name of Requestor*
7. Requestor Phone Number*
9. Requestor Address*
11. City*
12. State*
13. Zip Code*
15. Requestor Email*
19. Please provide the information below completely to determine the record requested.
21. Describe the Public Record You Are Requesting*
23. Date of Incident
    Date of Incident
24. Report Number
26. Address of Incident
28. City
29. State
30. Zip Code
34. Persons Involved
36. Full Name of Person(s) Involved
37. Relation to the Requestor
38. Date of Birth
    Date of Birth
40. Full Name of Person(s) Involved
41. Relation to the Requestor
42. Date of Birth
    Date of Birth
44. Do you want copies made?*

    1. No, please forward to the email above
    2. Yes. Please note that a fee may be applied and paid prior to the release of any copies. Refer to the schedule to determine applicable fees.
45. Financial Record Use*

    1. Yes
    2. No

    Will you use part or all of the records: to sell, to solicit, or advertise for sales, services, or commercial purposes?
46. Record Use*

    1. Yes
    2. No

    Are you any of the following: news, not-for-profit, scientific or academic institution?
48. Today's Date*
    Today's Date
49. Signature of Requestor*

    1. I, agree

    By selecting I agree option below you are giving your electronic signature.
53. Office Use Only
    Forward to the the FOIA Officer immediately upon receipt. Note date received.
55. Request received
56. FOIA Office received
57. Approved by
59. By
60. Period for response expires
61. Copies
62. Amount due
64. Department
65. Route to
66. Denied
67. By
69. Route to
70. Denial Letter sent
Leave This Blank:


72. 1. Receive an email copy of this form.
73. Email address

    This field is not part of the form submission.

74. Submit

* indicates a required field