MUNICIPAL FREEDOM OF INFORMATION

& PROTECTION OF PRIVACY ACT (MFIPPA)

ACCESS AND CORRECTION FORM

Please note:

An access/correction request for information will be processed in accordance with the time limits set out in the MFIPPA and regulations. The time limit to respond to your inquiry will begin from the date the request and the mandatory $5.00 application fee are received.

If paying by cheque, please make the cheque payable to the “County of Simcoe”.

Photocopies of originals will be provided in responding to requests. On-site viewing of originals may be arranged if required.

Part A: To be completed in full by the Requester
Access to General Records Access to Own Personal Information Correction of Own Personal Information	Directed to: County Clerk’s Department County of Simcoe 1110 Highway 26 Midhurst ON L9X 1N6 clerks@simcoe.ca
Details
Last Name	First Name
Company Name (if applicable)
Address	City	Province
Postal Code	Telephone - Day	Telephone - Evening
E-mail
Detailed description of requested records, personal information records or correction of personal information: (If request is for correction of personal information, please indicate the desired correction and attach any supporting documentation. If more space is needed please attach an additional page) __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________
Preferred method of access: Receive Copy Examine Original (on-site only)	Signature:	Date:
Part B: For Office Use Only
Request #	Date Application Fee Received:	Received By:	Ext. #:
Comments
Personal information contained on this form is collected under section 17 of the Municipal Freedom of Information and Protection of Privacy Act, and will be used to respond to your request. Questions regarding collection should be directed to the County Clerk’s Department, County of Simcoe, 1110 Highway 26, Midhurst, Ontario, L9X 1N6, 705-726-9300, ext. 1246 or email clerks@simcoe.ca
Note: If you are requesting information about yourself, your request is considered a “personal information request”.
Fee Charges for Requests for General Information If paying by cheque, please make the cheque payable to the “County of Simcoe”. Application Fee: ........................ $5.00 to be paid when you submit your request Search Time: ............................. $7.50 per ¼ hour required to search and retrieve records Record Preparation: .................. $7.50 per ¼ hour required to prepare records for release Photocopying: ........................... $0.20 per page Computer Programming: ........... $15.00 per ¼ hour to develop program to retrieve information CD: ............................................ $10.00 per CD Fee Charges for Requests for Personal Information If paying by cheque, please make the cheque payable to the “County of Simcoe”. Application Fee: ........................ $5.00 to be paid when you submit your request Photocopying: ........................... $0.20 per page Computer Programming: ........... $15.00 per ¼ hour develop program to retrieve information CD: ............................................ $10.00 per CD You will be given a fee estimate if anticipated fees are $25.00 or more. If the estimate of fees to be paid is $100.00 or more, you may be required to pay a 50% deposit. Please note that the fee charges are prescribed by section 45 of the Municipal Freedom of Information and Protection of Privacy Act. All monies are payable by cash, debit, money order or certified cheque only.