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Your Contact Information Date Name of Agency Att: Right to Information Officer Agency Address Email: Dear Sir / Madam RE: FORMAL REQUEST FOR INFORMATION UNDER THE GIPA ACT 2009 I request access to the following information understood to be held by (Name of Agency): 1. 2. 3. I enclose the application fee of $30.00. Please note I am providing my personal information for the specific purpose of this request for information, as such I ask (Agency Name) to ensure my personal information is not used for any other purpose without first having sought and obtained my consent to do so. Yours Sincerely Your Name Encl: Application Payment