Reduced Rate Copy Certification Form

DIRECTIONS: If you are eligible to receive free or reduced copy fees, complete all information requested below. Please TYPE or PRINT. Sign and date the bottom of the form. Submit the completed form by mail or email, along with your completed Public Records Request Form, to the Custodian of Records, 5825 Florida Blvd. Suite 2000, Baton Rouge, LA 70806 or by email to Publicrecords@ldaf.la.gov or by pressing the submit button below.
Name

First NameLast Name
Organization/Company
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email

Confirmation Emailexample@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I do hereby certify the following, check the appropriate boxes:

Certification for Reduced Copy fees - I am a citizen of the State of Louisiana who is indigent and lacks the means to pay $0.25 per copy. I will limit the use of the copies requested to a public purpose (including, but not limited to use in a hearing before any government regulatory commission). I further certify that this information is not for personal proprietary use. I understand that if, in the future, the Louisiana Department of Agriculture and Forestry determines my use of the documents to be different than represented here, the Department reserves the right to recover cost of copying at the normal rate.
Signature
Date Form is Complete

MonthDayYear

Step 1:

COMPLETE all information on this form.
Step 2:

SUBMIT completed form to the Custodian of Records by mail to 5825 Florida Blvd., Suite 2000, Baton Rouge, LA 70806, by email to Publicrecords@ldaf.state.la.us or by pressing the submit button below. DO NOT ATTACH PAYMENT WITH THIS FORM.
Step 3:

WAIT to receive invoice, if applicable. Once received, send payment as indicated on the invoice.
Name

First NameLast Name
Organization/Company
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email

Confirmation Emailexample@example.com
Requested Information: Please specify locations; business names; grower names; LDAF representative names; contents of list (contacts, email addresses); type of license (arborist, landscape horticulturist, pesticide dealer, structural pest control operator, grain dealer, warehouse, milk processor, hemp grower, etc.); permit (floral dealer, nursery stock dealer, cut flower dealer, sweet potato dealer, apiary, livestock dealer, etc.); registration (livestock auctioneers, commercial animal feed, fertilizer, seed dealer, etc.): and/or type of complaint/investigation (fire report, meat inspection, recorded brand, certificate of inspection and measurement, motor fuel quality, etc.). Attach additional pages, if necessary.
File Upload

Cancelof
Public Records Request, Begin Date

MonthDayYear
Public Records Request, End Date

MonthDayYear
I certify that I am 18 years of age. Requestor's Signature:
Date of Signature

MonthDayYear
Delivery Information (Check Appropriate Box)
Payment Method & Authorization

CARD, CHECK OR MONEY ORDER Duplication Fees: $0.25 per page (8½ X11 & 8 ½ X14)
Please be advised pursuant to La. Const. Art. XII, § and Title 44 of the Louisiana Revised Statutes, every person has the right to examine public records, except as otherwise provided by law. If your request is denied, specific reasons for denial will be provided. We are authorized to charge fees for providing copies of records, pursuant to La. R.S. 44:32.
Should be Empty:

Step 1:

Step 2:

Step 3:

Payment Method & Authorization