Public Service Request (Historic)
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Public Service Request (Historic)
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PSR
Public Service Request
Name (Print): ________________________________________________________________________
Address: ____________________________________________________________________________
City, State & Zip: _____________________________________________________________________
Telephone Number: __________________________________________________________________
Email: ______________________________________________________________________________
Time Total Amt.
Format Cost Spent Research Fee Due
Average hourly pay
Copies Letter/Legal = $.10/pg. x # of pages = ________ + ________ x for clerical staff = ________ = ________
CD or other
media Cost of media = ______ x quantity = ________ + ________ x Labor = ________ = ________
Research Hourly Wage of person performing research: _________ Amount of time spent: ______ Total cost (Wage x Time) = __________
Please include detailed description of your request for data and what it is to be used for:
_____________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
X_______________________________________ ______________________________
Signature Date of Request
Request taken by: __________________________Deputy Clerk.
************************** For Office Use Only *************************
Date Completed: ______________ By: _______________________________
Total Cost: $ _________________ Date Paid: _________________________
Rec’d by: ____________________ Treasurer’s Office Receipt #: ___________
Revised by: C. Smith on 12/7/2011
Public Service Request (Historic)
The original county PDF remains the downloadable record artifact and the printable source document.