Target State Agency,
attn: Records Custodian,
123 E Blunge St.,
Theirville, FLA 32000.

Dear Sirs:

This constitutes notice that on [__date1__] I furnished written notice that I would appear on [__date2__] to inspect and copy certain records. The request set out that, if you claimed any exemption, you were to identify the statutory basis for exemption and state why the exemption applied, with such claim of exemption being in writing.

I appeared at the stated date and time.

Then and there, you refused to furnish either the records or a written claim of exemption, contrary to the form of the statute in such cases made and provided, and against the peace and dignity of the State of Florida.

This notice is given pursuant to §119.12(1), Florda Statutes.

I certify that a copy hereof was served upon the records custodian identified above, by __method_of_delivery___ , on this ____ day of ______, 20__ .

Signed,



Your Name Here

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