Agency Head [or Freedom of Information Act Officer]
Name of Agency
Address of Agency
City, State, Zip Code

Re: Freedom of Information Act Request

Dear _____________:

        This is a request under the Freedom of Information Act.
        I request that a copy of the following documents [or documents
        containing the following information] be provided to me:  
        [identify the documents or information as specifically as possible.]
        In order to help to determine my status to assess fees, you should know 
        that I am [insert a suitable description of the requester and the
        purpose of the request.]

                [Sample requester descriptions:
        a representative of the news media affiliated with the ________________ 
        newspaper (magazine, television station, etc.), and this request is
        made as part of a news gathering and not for commercial use.
        affiliated with an educational or noncommercial scientific institution, 
        and this request is made for a scholarly or scientific purpose and not for
         commercial use.
        an individual seeking information for personal use and not for commercial use.
        affiliated with a private corporation and am seeking information for use in the 
        company's business.]
        [Optional]  I am willing to pay fees for this request up to a maximum of $____.
        If you estimate that the fees will exceed this limit, please inform me first.
        [Optional]  I request a waiver of all fees for this request.  Disclosure of the 
        requested information to me is in the public interest because it is likely to contribute
        significantly to public understanding of the operations or activities of the government 
        and is not primarily in my commercial interest.  [Include a specific explanation.]
        Thank you for your consideration of my request.


Name Address City, State, Zip Code Telephone Number [Optional]