State of New Jersey			
		Department of  Transportation			
		GOVERNMENT RECORDS REQUEST FORM			
					
Important Notice
The reverse side of this form contains important information related to your rights concerning government records. Please read it carefully.
In addition, please note that you may complete and submit requests electronically on the Internet at www.nj.gov/opra  	

	
Requester Information – Please Print	Payment Information	
First Name	
	
MI	
	
Last Name	

Company	

Mailing Address	

City	
	
State	
	
Zip	
	
Email	

Business Hours Telephone:	
Area Code	
	
Number	
	
Extension	

Fax	
Area Code	
	
Number	

Preferred Delivery:	
Pick Up	
	
US Mail	
	
On Site Inspect	

Check One:  Under penalty of N.J.S.A. 2C:28-3, I certify that I  _____HAVE  /  _____HAVE NOT  been convicted of any indictable offense under the laws of New Jersey, any other state, or the United States.	

Signature	
	
Date	

	

	

I agree to pay for fees related to this request no greater than	

$	

	

Select Payment Method	

Cash	

Check	

Money Order	

	

Fees:	
Pages 1-10	
@ $0.75	

Pages 11-20	
@ $0.50	

Pages 21 -	
@ $0.25	

Delivery:	
Delivery / postage fees additional depending upon delivery type.	

Extras:	
Extraordinary service fees dependent upon request.	

	
Record Request Information: To expedite the request, be as specific as possible in describing the records being requested. 	
 Request Access to:	  Inspect    	Or   Receive a Copy		

	
	
STATE USE ONLY	
Estimated Record Cost	

Special Cost	

Total Cost Estimated	

	

	

	

	Comments:	

Denied	

Approved-Records to be granted
in seven business days	

Approved – Records will take longer than seven business days	

	Tracking Information	
Final Cost	

ID #	

Total	

Ready Date	

Deposit	

Date Mailed or Picked Up	

Balance Due	

Total Pages	
	
•		
Balance Paid	

	

Date Paid	

Records Provided	

	

	

	

	

Custodian Signature	
	
Date	

In accordance with Requesting Access to Government Records Under the New Jersey Open Public Records Act (N.J.S.A. 47:1A-1 et seq.):
1.	In order to request access to government records under OPRA, you must complete all the required portions of and date this request form and deliver it in person during regular business hours, by mail, fax or electronically to the Department of Transportation. Your request is not considered filed until the Custodian of Records has received the completed request form. If you submit the request form to any other officer or employee of the Department of Transportation, that officer or employee does not have the authority to accept your request form on behalf of the Department of Transportation and you will be directed to the Custodian of Records for the Department. Descriptions of the divisions and agencies of the Department of Transportation can be found at www.nj.gov/transportation/
2.	Only requests submitted on this form to the Department of Transportation will be considered official requests under the Open Public Records Act.  Deadlines, restrictions and remedies will not apply to requests unless submitted on this form.
3.	The fees for duplication of a government record in printed form are listed on the front of this form. You will also be required to pay any special charges, special service charges or other additional charges authorized by State law or regulation. If estimated costs exceed the maximum amount you stated you were willing to pay, we will contact you for authorization before proceeding.  Payments made by check or money order should be made payable to the State of New Jersey.
4.	If it is necessary for the records custodian to contact you concerning your request, identifying information, such as your name, address and telephone number or an e-mail address is required.  Where contact is not necessary, anonymous requests are permitted; except that anonymous requests for personal information are not honored.
5.	Anonymous requests, when permitted, require a deposit of 50% of estimated fees if we believe the costs of the requested amount will exceed $15. You agree to pay the balance due upon delivery of the records.
6.	The Department of Transportation must deny access to a person who has been convicted of an indictable offense in New Jersey, any other state, or the United States, and who is seeking government records containing personal information that may pertain to the person’s victim or the victim’s family.
7.	The Department of Transportation must notify you that it grants or denies a request for access to government records within seven business days after receiving the request, provided that the record is currently available and not in storage.  If the record requested is not currently available or is in storage, the Department of Transportation will advise you within seven business days when the record can be made available and the estimated cost. You may agree to extend the time the Department of Transportation has for making records available, or for reviewing your request.
8.	You may be denied access to a government record if your request would substantially disrupt agency operation or the Department of Transportation is unable to reach a reasonable solution with you.
9.	If the Department of Transportation is unable to comply with your request for access to a government record, we will indicate the reasons for denial on the request form and send you a signed and dated copy.
10.	Except as otherwise provided by law or by agreement with the requester, if the Department of Transportation fails to respond to you within seven business days of receiving a request form, the failure to respond will be considered a denial of your request.
11.	If your request for access to a government record has been denied or unfilled within the time permitted by law, you have a right to challenge the decision by the Department of Transportation to deny access. At your option, you may either institute a proceeding in the Superior Court of New Jersey or file a complaint in writing with the Government Records Council (GRC).  You may contact the GRC by toll-free telephone at 866-850-0511, by mail at PO Box 819, Trenton, NJ, 08625, by e-mail at grc@dca.state.nj.us, or at their web site at www.nj.gov/grc The Council can also answer other questions about the law.
12.	Information provided on this form may be subject to disclosure under the Open Public Records Act.
Please submit form to:
Official Custodian of Records
Office of Inspector General
New Jersey Department of Transportation 
1035 Parkway Avenue
PO Box 600
Trenton, NJ 08625-0600
Fax:  609-530-6694
E-Mail:  NJDOT.OPRA@dot.state.nj.us
For more information, contact the Department of Transportation at (609)530-8045