KDB-R Application for Public Access to Records
NEPN/NSBA Code: KDB-R 

APPLICATION FOR PUBLIC ACCESS TO RECORDS 

Please print or type Date Submitted ___________________

To the M.S.A.D. #4 Records Access Officer:

I hereby apply to □ Inspect □ Obtain a copy of the following records @ .25 per page:

Be as specific as possible: ______________________________________________________

____________________________________________________________________________

____________________________________________________________________________

__________________________________ ________________________________

Individual Submitting Application Representing (if applicable)

Mailing Address ______________________________________________________________

Phone: _________________________ Fax: ___________________________


Signature: ______________________________________

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(For District Use Only)

Interim Response (If applicable) Date: _________________

__________________________________________________________________________________

__________________________________________________________________________________

Final Disposition

□ Approved Describe Disposition of Application __________________________________

________________________________________________________________

________________________________________________________________

Fee Charged (if any) $__________

□ Denied for the reason(s) checked below:

□ Confidential Disclosure □ Part of an Investigatory File

□ Unwarranted Invasion of Personal Privacy □ Exempted by Statute

□ Record of which the School District is Legal Custodian cannot be found

□ Other _____________________________________________________

□ Record is not maintained by the School District

_______________________________________________ ______________________

Signature of Records Access Officer Date

Note: You have a right to appeal this decision to: 

Ann Kirkpatrick, Superintendent
M.S.A.D. #4
25 Campus Drive, Drop 2
Guilford, ME 04443