Public Service Request Form (Historic)

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Public Service Request Form (Historic)

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PSR
PUBLIC SERVICE REQUEST
Name

Address

City, State, Zip

Telephone

Cost for Data requested
A. Research Charge: $______/hour (less than 5 minutes are free)

B. Copies: .10/copy Letter

C. Tape or video recording: $1.50 per tape.

D. CD: $10.00 per CD. (Labor is included.)

Detailed Explanation of data requested:

X
Signature Date of request
*************************for office use***************************
Date Completed: By:
Total Cost: $ Date Paid: Rec’d by:
Treasurer’s Office Receipt #:

Taney County Courthouse Annex, PO Box 156, 139 David St, Forsyth, MO 65653

Revised 03/27/07

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Public Service Request Form (Historic)

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