Form Adm 0028 – Fill Out and Use This PDF

	STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION	Page 1 of 2
	RECORD DISCLOSURE REQUEST
		Front
	ADM-0028 (REV. 5/97)	ATTACHMENT D

PERSONAL INFORMATION NOTICE

Pursuant to the Federal Privacy Act (P.L. 93-579) and the Information Practices Act of 1977 (Civil Code Sections 1798, et seq.), notice is hereby given for the request of personal information by this form. The requested personal information is voluntary. The principal purpose of the voluntary information is to facilitate the processing of this form. The failure to provide all or any part of the requested information may delay processing of this form. No disclosure of personal information will be made unless permissible under Article 6, Section 1798.24 of the IPA of 1977. Each individual has the right upon request and proper identification, to inspect all personal information in any record maintained on the individual by an identifying particular. Direct any inquiries on information maintenance to your IPA Officer.

Instructions For the Requester:

For the disclosure of *Public records, complete sections A and B.

For the disclosure of *Personal/Confidential records, complete sections A, B, and C.

(See Reverse Side For The Definitions)

A.The Public Records Act exempts disclosure of records pertaining to pending claims and litigation to which the public agency is a party. (GOV. CODE, § 6254 B) Additionally, federal law broadly prohibits the disclosure of various documents in any action for damages against the state. (GOV. CODE § 6254 K AND 23 U.S.C., § 409) In order to comply with the applicable provisions of law, by your signature, you must certify that the material and information sought by you is not pertaining to a pending claim or action for damages, where a public agency is a party. If a public agency is a party to a pending claim or action for damages, please contact the HQ Caltrans Records Management or District Claims Officer.

REQUESTER'S SIGNATURE	DATE

B. REQUESTED BY

DEPARTMENT/DIVISION/OFFICE OR BUSINESS NAME			BUSINESS PHONE
BUSINESS ADDRESS	CITY	STATE	ZIP CODE
NAME (Typed or Printed)			OCCUPATION
REQUESTER'S SIGNATURE			DATE

DESCRIPTION OF MATERIAL REQUESTED (Indicate Dates & Locations In The Description)

THE PRINCIPAL PURPOSE(S) FOR WHICH INFORMATION IS TO BE USED

C.FOR REQUEST FOR PERSONAL INFORMATION ONLY:

If you are not the subject of the personal information requested, be aware that intentional disclosure of the information may subject you to a civil action under Section 1798.53 of the Civil Code. If you are not the data subject, attach a written consent or have the data subject sign below (the voluntary written consent must be within 30 days of the requested disclosure or an agreed written time limit).

I, (print)		, hereby voluntarily permit the requested information to be released for the described purpose above.

RETENTION OF DISCLOSURE

According to state law, each agency shall retain this form for at least three (3) years after the disclosure for which the accounting is made, or until the record is destroyed, whichever is shorter. California Civil Code (IPA § 1798.27).

DEFINITIONS AS USED OF THIS FORM

Disclose - means to disclose, release, transfer, disseminate, or otherwise communicate all or any part of any record orally, in writing, or by electronic or any other means to any person or entity.

Public Records - includes any writing containing information relating to the conduct of the public's business prepared, owned, used or retained by any state or local agency regardless of physical form or characteristics.

Personal Information - means any information that is maintained by an agency that identifies or describes an individual.

NOTE: There are exemptions to disclosures in Public & Personal Records. If you are not sure, check with Legal.

COPY COST AND COLLECTION

The requester should pay the appropriate fee, if any, to the Cashier's Unit. Records can be released upon proof of receipt of payment. Refer to the Public Access To Department Records and Personal Information Guidelines (Attachment C) for guidance Prices are subject to change without notice. Contact the Reprographics Unit or Microfilm Unit for the latest rates.

The Cashiers Unit (counter) is located at 1820 Alhambra Blvd., 2nd floor.

	DESCRIPTION		QUANTITY		COST PER UNIT							SUBTOTAL
PERSONAL RECORDS (Any Size Paper)				$	.10		Per Page				$	0.00
	PUBLIC RECORDS
8.5" x 14" OR SMALLER, 20# COPIES				$	.10		Per Page				$	0.00
11" x 17" REDUCED DRAWINGS (C Size)				$	.10		Per Page				$	0.00
	Size:			$							$	0.00
	ENGINEERING (C-E SIZE)
20# BOND	Size:			$	.05		Square Foot				$	0.00
VELLUM	Size:			$	.08		Square Foot				$	0.00
BLUELINES	Size:			$	.05		Square Foot				$	0.00
	Size:			$							$	0.00
	MICROFILM
APERTURE CARDS COPIES				$	.25		Each Card				$	0.00
COPIES MADE FROM MICROFILM		Size: 11" X 17"		$	1.00 Per Sheet						$	0.00
		Size: 24" X 36"		$	3.00 Per Sheet						$	0.00
PUBLICATIONS & CONTRACTOR'S PAYROLL RECORDS			SPECIAL RATES	CHECK THE GUIDELINES							$
			PLEASE PAY TOTAL					?		?	$	0.00
CHECK/RECEIPT NUMBER:				AMOUNT PAID:

For individuals with sensory disabilities, this document is available in alternate formats. For information call (916) 654-6410 or TDD (916) 654-3880 or write Records ADA Notice and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.