Form Center

2. 310 E. Torrance Ave., Pontiac, IL 61764
   
4. Jackie Dever, R.N., BSN

   Administrator 

6. FREEDOM OF INFORMATION REQUEST
8. Requester:
10. Name*
11. Address*
13. City, State, Zip Code*
14. Phone Number*
16. Records sought (be specific): Property requests should include 911 address if known and property identification number.*
18. Signature of Requester*
19. Date*
21. Is this request for Commercial Purpose*

    (It is a violation of the Freedom of Information Act for a person to knowingly obtain a public record for a commercial purpose without disclosing that it is for a commercial purpose, if requested to do so by the public body. 5/140.3.1(c).

    1. Yes
    2. No
23. Are you requesting a fee waiver?*

    If you are requesting  that the public body waive any fees for copying documents, you must attach a statement of the purpose and whether the request is to access or disseminate information regarding the health, safety and welfare or legal rights of the general public.  5 ILCS1 40/6 (c).

    1. Yes
    2. No
27. For Agency Use Only
29. Date Request Received
30. Received by:

    1. Mail
    2. Phone
    3. In Person
    4. E-Mail
    5. Fax
32. Date Response Must Be Made By:
34. Agency: Livingston County Health Department
36. Address: 310 E. Torrance Avenue, Pontiac, IL 61764
37. Phone Number: (815) 844-7174
39. Name
40. Title
42. Response:
44. Records Found
45. Records Not Found
46. Date E-Mailed
47. Date Mailed
49. Date E-Mailed
50. Date Faxed
52. Status Records Furnished:
54. Supervisor Signature
55. Date
57. Livingston County Public Health Department does not discriminate in admission to programs or activities or treatment of employment in programs or activities in compliance with the Illinois Human Rights Act, The U.S. Civil Rights Act,: Section 504 of the Rehabilitation Act; the Age discrimination Act; The Age Discrimination in Employment Act; and the U.S. and Illinois Constitution and the American with Disabilities Act. If you feel you have been discriminated against you have a right to file a complaint with the Livingston County Public Health Department, (815) 844-7174.
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59. 1. Receive an email copy of this form.
60. Email address

    This field is not part of the form submission.

61. Submit Submit and Print

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