Offsite Records Storage Request

		Requested Date*

Company Name

FEIN

Address

City

State

Zip

Telephone Number

Requestor Address same as Company Address

Reason for Request

Additional Details

Choose a document to upload (if needed) (PDF, Word, Excel, RTF, GIF, JPEG, JPG)

**If you want a copy of your waiver request, print it before submitting the form**

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