Kansas Open Records Act (KORA)Kansas Open Records Act (KORA)"*" indicates required fieldsDate (mm/dd/yyy)* MM slash DD slash YYYY Name* First Last Phone*Driver License #/ State*Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Record(s) Sought: Please make sure your request is as SPECIFIC AS POSSIBLE so that we can attempt to fulfill it accurately and completely.*Certificate of Compliance with K.S.A. 21-3914 & K.S.A. 45-2209(c)*I, _______________________________ (requester) understand that no person shall receive, for the purposes of selling or offering for sale, any property or service to person listed therein, any list of names or addresses contained in or derived from public record. In accordance with these provisions, I certify that I do not intend to and will not, use any list of names or addresses contained in or at any address listed; neither will I sell, give or other make available to any person, any list of names or addresses contained in or derived from the records or information for the purpose of allowing that person to sell or offer for sale any property or service to any circumstances provided in K.S.A. 21-2914. Kansas law provides that a public agency may charge and require advance payment of a fee for providing access to or furnishing copies of public record. _______________________________________________ Signature of requestor (will sign when request is picked up) I agree to the Certificate of ComplianceFOR OFFICE USE ONLYDate & Time received: _____________________________ Date & Time provided: ____________________________ Staff time: $______________ (min. of $10.00/hour) Fees: _____ (# of pages) x .50 = __________ Mailing: _________ Total fee: _________________ Date Paid: _____________ Staff Signature & initials ________________________________________________________NameThis field is for validation purposes and should be left unchanged.
