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2. 

4. PUBLIC RECORDS REQUEST

6. Name
7. Phone Number
9. Address
11. Date Requested
12. Date Required
14. Email Address:
16. Public Records Requested

18. The South Jefferson Landbank will respond to this request for public records pursuant to Neb. Rev. Stat. §§ 84-712 to 712.09 and all other applicable law. The South Jefferson Landbank, providing this form for your request, does not guarantee it may disclose the public records requested, and does not waive any rights, obligations, or options available to it pursuant to law in responding to this request. The South Jefferson Landbank reserves the right to withhold certain public records pursuant to Neb. Rev. Stat. §§ 84-712 to 712.09 and all other applicable law.

    When information is compiled, you will be contacted by phone. Below is an estimate of the expected cost of the copies requested. You have 10 business days from receipt of this notice to review the estimated costs, and (1) request the South Jefferson Landbank to fulfill the original request, (2) negotiate to narrow or simplify the request, or (3) withdraw the request. If the South Jefferson Landbank does not have a response from you within 10 business days, the South Jefferson Landbank shall not fulfill the request.

20. Office Use Only:

    Do not write in this space

    ______Labor @ $15.00 per hour beyond first 8 cumulative hours $ _________ 

    ______Copies @ $.25bw/.50color each (for paper, toner, equipment usage and fees $ _________ 

    ______Special Copies ___________ $ _________ 

    ______Pages of fax at $2.00 1st page and 30¢ each additional page $ _________ 

    ______Postage $ _________ 

    Total cost due upon receipt $ _________

22. Please remit to: 

    South Jefferson Landbank 

    PO Box 554 

    Fairbury, Nebraska 68352

    landbank@fairburyne.org

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24. 1. Receive an email copy of this form.
25. Email address

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