FLORENCE COUNTY

FREEDOM OF INFORMATION ACT

REQUEST FORM

Mail completed form to: Florence County Administrator’s Office, 180 N. Irby St. MSC-G, Florence, SC 29501

When completing the form below please print the requested information.

Date of Request: __________________________________

Name: __________________________________________

Address: ________________________________________

City: _________________State__________ Zip_________

Phone Number: ___________________ E-Mail Address: ___________________________

When completing the request, it is VERY important to be as SPECIFIC AS POSSIBLE. Your request may be delayed if you are not clear about the information you are seeking.

Information Requested/Detailed Description: ________________________________________________________

§30-2-50 prohibits a person or private entity from knowingly obtaining personal information from a local government or other political subdivision for commercial purposes. Violators are guilty of a misdemeanor and upon conviction are subject to a $500 fine and/or jail time up to one year. By signing below you are acknowledging that you have read the above statement regarding § 30-2-50.

Signature: ______________________________________

_____________________________________________________________________________________________

For Office Use Only:

Received: Hand-Delivered_____ Mail ____ Fax ____ E-Mail_______ by ____________________________

Request assigned to: ______________________ Date of Completion: _______________________

Date of Assignment: _________________________ Fee for Services Rendered: _________________

Comments: _____________________________ Method of Payment: ______________________

_____________________________________________________________________________________________

I have received______ pages in response to the Freedom of Information Act request above.

Signature: ____________________________________________________ Date_______________________

To View the South Carolina Freedom of Information Act in its entirety, go to http://www.scstatehouse.gov/code/t30c004.php