Borough of Wallington
OPEN PUBLIC RECORDS ACT REQUEST FORM
			24 Union Blvd, Wallington, NJ 07057
(973) 777-0318
xxxx@xxxxxxxxxxxx.xxx Frank Belli

Important Notice
The last page of this form contains important information related to your rights concerning government records. Please read it carefully.

Requestor Information – Please Print	Payment Information

First Name 		 MI 		 Last Name 		 E-mail Address  						 Mailing Address 						 City 	 State 		 Zip 	
Telephone 			 FAX 	 Pick	On-Site
Preferred Delivery:   Up 	 US Mail 	 Inspect 	 Fax 	 E-mail 	

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

2.

I, or another person, purpose;

WILL /	WILL NOT use the requested government records for a commercial

3.	I	AM /	AM NOT seeking records in connection with a legal proceeding.
Signature	Date

Maximum Authorization Cost $

Select Payment Method
Cash		Check	Money Order Fees:	Letter size pages - $0.05
per page
Legal size pages - $0.07 per page
Other materials (CD, DVD, etc) – actual cost of material
Delivery: Delivery / postage fees additional depending upon delivery type.
Extras:  Special service charge
dependent upon request.

Record Request Information: Please be as specific as possible in describing the records being requested. Also, please note that your preferred method of delivery will only be accommodated if the custodian has the technological means and the integrity of the records will not be jeopardized by such method of delivery.

Note: If you confirmed above that the records sought are in connection with a legal proceeding, identification of that proceeding is required below.

AGENCY USE ONLY		AGENCY USE ONLY		AGENCY USE ONLY	

Est. Document Cost	

 			Disposition Notes
Custodian: If any part of request cannot be delivered in seven business days,
detail reasons here.

In Progress	-	Open Denied	-	Closed
Filled	-	Closed

Partial	-	Closed		Tracking Information	Final Cost
Tracking #			Total Rec’d Date			Deposit
Ready Date			Balance Due Total Pages			Balance Paid
Records Provided

	
Custodian Signature	Date	
Est. Delivery Cost	 						
Est. Extras Cost	 						
Total Est. Cost	 						
Deposit Amount	 						
Estimated Balance	 						
Deposit Date	 						

DEPOSITS
The custodian may require a deposit against costs for reproducing documents whenever the custodian anticipates that the documents requested will cost in excess of $5 to reproduce. N.J.S.A. 47:1A-5(f).

Where a special service charge is warranted under OPRA, that amount will be communicated to you as required under the statute. You have the opportunity to review and object to the charge prior to it being incurred. If, however, you approve of the fact and amount of the special service charge, you may be required to pay a deposit or pay in full prior to reproduction of the documents.

YOUR REQUEST FOR RECORDS IS DENIED FOR THE FOLLOWING REASON(S):
(To be completed by the Custodian of Records – check the box of the numbered exemption(s) as they apply to the records requested. If multiple records are requested, be specific as to which exemption(s) apply to each record. Response is due to requestor as soon as possible, but no later than seven (7) or fourteen (14) business days. See page 5 for additional response details)

N.J.S.A. 47:1A-1.1
Inter-agency or intra-agency advisory, consultative or deliberative material Legislative records
Law enforcement records:
Medical examiner photos
Criminal investigatory records (however, N.J.S.A. 47:1A-3(b) lists specific criminal investigatory information which must be disclosed)
 Victims’ records and/or OPRA requests submitted by victims seeking their own records
Personal firearms records or personal identifying information connected to any license authorizing hunting with a firearm. Trade secrets and proprietary commercial or financial information
Any record within the attorney-client privilege
Administrative or technical information regarding computer hardware, tablets, telephones, electronic computing devices, software applications, and networks or devices operation them which, if disclosed would jeopardize computer security
Emergency or security information or procedures for any buildings or facility which, if disclosed, would jeopardize security of the building or facility or persons therein
Security measures and surveillance techniques which, if disclosed, would create a risk to the safety or persons, property, electronic data or software
Security alarm system activity and access reports, including video footage the disclosure of which does not compromise the integrity of the security system
Information which, if disclosed, would give an advantage to competitors or bidders including detailed or itemized cost estimates prior to bid opening
Information generated by or on behalf of public employers or public employees in connection with: Any sexual harassment complaint filed with a public employer
Any grievance filed by or against an employee
Collective negotiations documents and statements of strategy or negotiating
Information that is a communication between a public agency and its insurance carrier, administrative service organization or risk management office
Information that is to be kept confidential pursuant to court order
Certificate of honorable discharge issued by the United States government (commonly Form DD-214 or NGB-22) filed with a public agency
Oath of allegiance, oath of office, or other affirmation; except that full name, title, and oath date. Privacy Information:
Social security numbers
Credit card or debit card numbers Bank account information
Month and day of birth
Personal e-mail address required by a public agency for government applications, services, or programs Telephone numbers
Drivers’ license numbers
Primary or secondary addresses for covered persons or immediate family members per N.J.S.A. 47:1B-1 (Daniel’s Law) Portion of any document disclosing personal information of any person provided to a public agency for sole purpose of receiving official notifications
Lists (including personal information) of persons identifying as in need of special assistance in the event of an emergency maintained by a municipality or county
Portion of any record disclosing the personal identifying information of a person under 18 years old Personal identifying information contained on domestic animal permits, license, and registrations. Metadata
New Jersey Firemen’s Association financial relief applications Owner and maintenance manuals
HIPAA information and indecent or graphic images of a person’s intimate parts as defined in N.J.S.A. 47:1A-5.2 Certain records of higher education institutions:
Research records
Questions or scores for exam for employment or academics Charitable contribution information
Rare book collections gifted for limited access Admission applications

Student records, grievances or disciplinary proceedings revealing a students’ identification Biotechnology trade secrets N.J.S.A. 47:1A-1.2
Convicts requesting their victims’ records N.J.S.A. 47:1A-2.2
Ongoing investigations of non-law enforcement agencies (must prove disclosure is inimical to the public interest) N.J.S.A. 47:1A-3(a)
Public defender records N.J.S.A. 47:1A-5(k)
Upholds exemptions contained in other State or federal statutes and regulations, Executive Orders, Rules of Court, and privileges created by State Constitution, statute, court rule or judicial case law N.J.S.A. 47:1A-9
Personnel and pension records (however, the following information must be disclosed:
•	An individual’s name, title, position, salary, payroll record, length of service, date of separation and the reason for such separation, and the amount and type of any pension received
•	When required to be disclosed by another law, when disclosure is essential to the performance of official duties of a person duly authorized by this State or the US, or when authorized by an individual in interest
•	Data contained in information which disclose conformity with specific experiential, educational or medical qualifications required for government employment or for receipt of a public pension, but not including any detailed medical or psychological information N.J.S.A. 47:1A-10
N.J.S.A. 47:1A-1
 “a public agency has a responsibility and an obligation to safeguard from public access a citizen's personal information with which it has been entrusted when disclosure thereof would violate the citizen's reasonable expectation of privacy.”
Burnett v. County of Bergen, 198 N.J. 408 (2009). Without ambiguity, the court held that the privacy provision “is neither a preface nor a preamble.” Rather, “the very language expressed in the privacy clause reveals its substantive nature; it does not offer reasons why OPRA was adopted, as preambles typically do; instead, it focuses on the law’s implementation.” “Specifically, it imposes an obligation on public agencies to protect against disclosure of personal information which would run contrary to reasonable privacy interests.”

Executive Order No. 21 (McGreevey 2002)
 Records where inspection, examination or copying would substantially interfere with the State's ability to protect and defend the State and its citizens against acts of sabotage or terrorism, or which, if disclosed, would materially increase the risk or consequences of potential acts of sabotage or terrorism.
 Records exempted from disclosure by State agencies’ proposed rules.
Executive Order No. 26 (McGreevey 2002)
Certain records maintained by the Office of the Governor
Resumes, applications for employment or other information concerning job applicants while a recruitment search is ongoing
Records of complaints and investigations undertaken pursuant to the Model Procedures for Internal Complaints Alleging Discrimination, Harassment or Hostile Environments
Information relating to medical, psychiatric or psychological history, diagnosis, treatment or evaluation Information in a personal income or other tax return
Information describing a natural person's finances, income, assets, liabilities, net worth, bank balances, financial history or activities, or creditworthiness, except as otherwise required by law to be disclosed
 Test questions, scoring keys and other examination data pertaining to the administration of an examination for public employment or licensing
 Records in the possession of another department (including NJ Office of Information Technology or State Archives) when those records are made confidential by regulation or EO 9.
Other Exemption(s) contained in a State statute, resolution of either or both House of the Legislature, regulation, Executive Order, Rules of Court, any federal law, federal regulation or federal order pursuant to N.J.S.A. 47:1A-9(a).
(Please provide detailed information regarding the exemption from disclosure for which you are relying to deny access to government records.
If multiple records are requested, be specific as to which exemption(s) apply to each record.)

REQUEST FOR RECORDS UNDER THE COMMON LAW

If, in addition to requesting records under OPRA, you are also requesting the government records under the common law, please check the box below.

A public record under the common law is one required by law to be kept, or necessary to be kept in the discharge of a duty imposed by law, or directed by law to serve as a memorial and evidence of something written, said, or done, or a written memorial made by a public officer authorized to perform that function, or a writing filed in a public office. The elements essential to constitute a public record are that it be a written memorial, that it be made by a public officer, and that the officer be authorized by law to make it.
 Yes, I am also requesting the documents under common law.
If the information requested is a "public record" under common law and the requestor has a legally recognized interest in the subject matter contained in the material, then the material must be disclosed if the individual's right of access outweighs the State's interest in preventing disclosure.

Please set forth your interest in the subject matter contained in the requested material:

Note that any challenge to a denial of a request for records under the common law cannot be made to the Government Records Council, as the Government Records Council only has jurisdiction to adjudicate challenges to denials of OPRA requests. A challenge to the denial of access under the common law can be made by filing an action in Superior Court.

1.	All “government records” as defined in N.J.S.A. 47:1A-1.1 are subject to public access under the Open Public Records Act (“OPRA”), unless specifically exempt.
2.	A request for access to a government record under OPRA must be in writing, hand-delivered, mailed, transmitted electronically, or otherwise conveyed to the appropriate custodian. N.J.S.A. 47:1A-5(g). In accordance with OPRA, custodians will generally have seven (7) business days to respond, unless:
•	The requestor seeks “immediate access” records as outlined in N.J.S.A. 47:1A-5(e); where the custodian must respond “immediately” disclosing responsive records not to exceed twenty-four (24) months old.
•	The requestor seeks information required to be disclosed by N.J.S.A. 47:1A-3(b), where the custodian must respond disclosing the information within twenty-four (24) hours or as a soon as practical;
•	The requestor is a seeking records for a “commercial purpose” as defined in N.J.S.A. 47:1A-1.1, where the response time frame is fourteen (14) business days, but the custodian shall notify the requestor of the additional time within seven (7) business days. N.J.S.A. 47:1A-5(i). However, the response time frame can be reduced to seven (7) business days upon payment of no more than two times the cost to produce the responsive records.
•	The requestor is seeking records requiring review for compliance with “Daniel’s Law” (N.J.S.A. 47:1B-1, et seq.), where the response time frame is fourteen (14) business days, but the custodian shall notify the requestor of the additional time within seven (7) business days. N.J.S.A. 47:1A-5(i).
•	Fire district employing one or fewer full-time employees serving as custodians may add seven (7) business days to the seven (7) or fourteen (14) business day response time frames.
The applicable response time does not commence until the custodian receives the request form. N.J.S.A. 47:1A-5(h). If you submit the request form to any other officer or employee, the recipient must either forward the request to the appropriate custodian or direct you to the appropriate custodian. Id.
3.	Requestors are not required to use this OPRA request form; however, a written equivalent not containing the form requirements of N.J.S.A. 47:1A-5(f) and N.J.S.A. 47:1A-5(g) may be denied by a custodian.
4.	Requestors may submit requests anonymously. A request submitted anonymously shall not be considered incomplete.
N.J.S.A. 47:1A-5(f). If you elect not to identify yourself accurately or provide an accurate address, e-mail address, or telephone number, the custodian is not required to respond until you reappear before the custodian seeking a response to the original request. Further, anonymous requestors are prohibited from filing a complaint with either the GRC or the Courts. N.J.S.A. 47:1A-6.
5.	The fees for duplication of a “government record” in printed form are listed on page 1 of this form. The custodian will notify you of any special service charges or other additional charges authorized by State law or regulation before processing your request. Payment shall be made by cash, check or money order payable to the responding agency.
6.	You may be charged a prepayment or deposit when a request for copies exceeds $5.00. The custodian will contact you and advise you of any deposit requirements. You agree to pay the balance due upon delivery of the records.
7.	Under OPRA, a custodian 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 pertaining to the person’s victim or the victim’s family. N.J.S.A. 47:1A-2.2. This includes anonymous requests for said information.
8.	By law, the responding agency must notify you that it grants or denies a request for access to government records within applicable response time frame after the custodian receives the request. If the record requested is in storage, the custodian will advise you within seven (7) or fourteen (14) business days after receipt of the request when the record can be made available and the estimated cost for reproduction within no more than twenty-one (21) business days from date of notification.
N.J.S.A. 47:1A-5(i).
9.	You may be denied access to a government record if your request would substantially disrupt agency operations and the custodian is unable to reach a reasonable solution with you. N.J.S.A. 47:1A-5(g).
10.	If the custodian is unable to comply with your request for access to a government record, they will indicate the specific bases for denial on the request form or other written correspondence and send it to you.
11.	Except as otherwise provided by law or by agreement with the requester, if the custodian fails to respond to you in writing within seven (7) or fourteen (14) business days of receiving a request, the failure to respond is a deemed denial of your request.
N.J.S.A. 47:1A-5(g); N.J.S.A. 47:1A-5(i).
12.	If your request for access to a government record has been denied or unfilled within the seven (7) or fourteen (14) business days required by law, you have a right to challenge the decision by the responding agency to deny access. At your option, you may either: 1) institute a proceeding in the Superior Court of New Jersey; or 2) file a complaint with the Government Records Council (“GRC”) by completing the Denial of Access Complaint Form. All questions regarding complaints filed in Superior Court should be directed to the Court Clerk in your County. Questions regarding the GRC’s Denial of Access Complaint process can directed to the GRC toll-free telephone at 866-850-0511, by mail at PO Box 819, Trenton, NJ, 08625, by e-mail at xxxxxxxxxx.xxxxxxx@xxx.xx.xxx, or at their web site at www.state.nj.us/grc. The Council can answer general inquiries about OPRA.
13.	Information provided on this form may be subject to disclosure under the Open Public Records Act.