Name __________________________________




Date Request Received:__________

Request was made (check one)

q  by requester on this form

q  by telephone

q  in writing other than on form

(attach original request)

Date Response Sent: ____________

(attach copy)

q  Identification Verified

Type: ________________________
Number: ______________________

q  Itemized Cost Estimate Attached

Address ________________________________


E-mail address __________________________

Phone _________________________________

I am a (check one):

q  Citizen of the Commonwealth of Virginia

q  Member of the Press referenced in Va. Code 2.2-3704

News Organization ____________________

Requesters may be asked to provide verification that they are citizens of the Commonwealth or a member of the press referenced in Va. Code 2.2-3704.


I am requesting access to the following records (please be as specific as possible, and attach additional paper if necessary _______________________________________________


Reasonable costs may be assessed in connection with this request. A current schedule of costs appears in Regulation KBA-R Requests for Public Records. If the costs associated with this request are expected to exceed $200, the requestor will be asked to pay the estimated costs before the request is processed.

In addition, the requestor may ask for an advance determination of the cost of the request. Please indicate here if you would like an advance determination of cost.

Yes ___ No ___


If you are requesting copies, please specify the format in which you would like to receive them. Alleghany County school division will provide the record(s) in the requested format if that medium is used by it in the regular course of its business.


Specify format desired (if available):

q  Photocopies

q  E-mail (give address): ___________________

q  Website posting

q  Other (please specify): ___________________


________________________________ ______________________

Signature Date



Alleghany County Public Schools

Office of the Superintendent

100 Central Circle

Low Moor, Virginia 24457

Phone: (540) 863-1800 / Fax: (540) 863-1804