REQUEST TO ACCESS A GOVERNMENT RECORDDATE:____________________________TO:________________________________________________________________________FROM:________________________________________________________________________________Name or Alias________________________________________________________________________________
Contact Information________________________________________________________________________________

Although you are not required to provide any personal information, you should provide enough information toallow the agency to contact you about this request. The processing of this request may be stopped if the agency
is unable to contact you. Therefore, please provide any information that will allow the agency to contact you(name or alias, telephone or fax number, mailing address, e-mail address, etc.).

I WOULD LIKE THE FOLLOWING GOVERNMENT RECORD:
Describe the government record as specifically as possible so that it can be located. Try to provide a record
name, subject matter, date, location, purpose, or names of persons to whom the record refers, or otherinformation that could help the agency identify the record. A complete and accurate description of thegovernment record you request will prevent delays in locating the record. Attach a second page if needed.

I WOULD LIKE:(please check one or more of the options below)

To inspect the government record.
A copy of the government record: (Please check one of the options below.) See the back of this pagefor information about fees that you may be required to pay for agency services to process your record
request. Note: Copying and transmission charges may also apply to certain options.
Pick up at agency (date and time): ____________________________________________Mail
Fax (toll free and only if available)
Other, if available (please specify): ____________________________________________
If the agency maintains the records in a form other than paper, please advise in which
format you would prefer to have the record.
ElectronicAudio

Other (please specify):_____________________

Check this box if you are attaching a request for waiver of fees in the public interest(see waiver information on back).

SEE BACK FOR IMPORTANT INFORMATIONOIP 1 (rev. 9/12/01)

FEES FOR PROCESSING RECORD REQUESTS
You may be charged fees for the services that the agency must perform when processing your record
request, including fees for making photocopies and other lawful fees. The first $30 of fees chargedfor searching for a record, reviewing, and segregating will not be charged to you. Any amountover $30 will be charged to you. Fees are as follows:
Search for a Record
Review and Segregation of a Record$2.50 for 15 minutes$5.00 for 15 minutes

WAIVER OF FEES IN THE PUBLIC INTEREST
Up to $60 of fees for searching for, segregating and reviewing records may be waived when the waiverwould serve the public interest as described in section 2-71-32, Hawaii Administrative Rules. If you
wish to apply for a waiver of fees in the public interest, you must attach to this request a statement offacts, including your identity as the requester, to show how the waiver of fees would serve the publicinterest. The criteria for this waiver, found at section 2-71-32, Hawaii Administrative Rules, are:
(1)
(2)
(3)

The requested record pertains to the operations or activities of an agency;
The record is not readily available in the public domain; andThe requester has the primary intention and the actual ability to widely disseminate
information from the government record to the public at large.

AGENCY RESPONSE TO YOUR REQUEST FOR ACCESS
The agency to which you addressed your request must respond within a set time period. The agency
will normally respond to you within 10 business days from the date it receives your request; however, inextenuating circumstances the agency must respond within 20 business days from the date of yourrequest. If you have questions about the response time, you may contact the agency’s UIPA contact
person. If you are not satisfied with the agency’s response, you may call the Office of Information
Practices at 808-586-1400.

REQUESTER’S RESPONSIBILITIESYou have certain responsibilities under §2-71-16, Hawaii Administrative Rules. You may obtain a copyof these rules from the Lieutenant Governor's Office or from the Office of Information Practices. Theseresponsibilities include making arrangements to inspect and copy records, providing further clarification
or description of the requested record as instructed by the agency's notice, and making a prepaymentof fees, if assessed.

OIP 1 (rev. 9/12/01)