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2. This form is being provided to potential requestors as a helpful guide for composing an effective request for public records. Requestors should not consider this form to be mandatory. KORA requires requests to be in writing. Email is an acceptable form of written request. Attention: Official Designated Agency Records Custodian, Jill Bronaugh, Public Information Manager, Office of the State Fire Marshal, 800 SW Jackson, Suite 104, Topeka, KS 66612-1216, (785) 296-3403, FAX: (785) 296-0151, Email: jill.bronaugh@ks.gov (Use subject line: “Open Records Request”).
4. Today's Date
   Today's Date
6. Under the Kansas Open Records Act (KORA) K.S.A. 45-215 et seq., I request access to or copies of the following records (please be as specific as possible in describing the records you want and the time period your request covers; attach PDF if necessary):
8. I request the information be provided in the following format if possible (please check one):

   1. Paper
   2. Electronic
10. Name
11. Email Address
13. Address
15. City
16. State
17. Zip Code
19. Phone Number
20. Fax Number
22. Upload PDF for additional information
24. In accordance with K.S.A. 45-220(c)*, I certify that I do not intend to, and will not: (A) Use any list of names or addresses contained in or derived from the records or information for the purpose of selling or offering for sale any property or service to any person listed or to any person who resides at any address listed; or (B) sell, give or otherwise make available to any person any list of names or addresses contained in or derived from the records or information for the purpose of allowing that person to sell or offer for sale any property or service to any person listed or to any person who resides at any address listed. The unlawful use of lists of names and addresses may result in a civil penalty of up to $500, pursuant to K.S.A. 45-230. I additionally certify that, if access to public records or the purpose for which the records may be used is limited pursuant to K.S.A. 45-221 or K.S.A. 45-230, I have a right of access to the records and the basis of that right.
26. *Note: You may locate and review a copy of these statutes by using the following links:
28. K.S.A. 45-220(c)
    http://www.ksrevisor.org/statutes/chapters/ch45/045_002_0020.html
30. K.S.A. 45-221
    https://www.ksrevisor.org/statutes/chapters/ch45/045_002_0021.html
32. K.S.A. 45-230
    https://www.ksrevisor.org/statutes/chapters/ch45/045_002_0030.html
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34. 1. Receive an email copy of this form.
35. Email address

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36. Submit

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