Fillable DATA/INFORMATION REQUEST Tom Green County Attention: Elections 113 (Tom Green County)

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DATA/INFORMATION REQUEST Tom Green County Attention: Elections 113 (Tom Green County)

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DATA/INFORMATION REQUEST
Date ____________ Telephone No. __________________ Fax No. ______________________
Name/Agency/Company _____________________________ Method of Payment: ____________
Address _________________________________________ Cash _________ Check __________
Email _____________________________ Note: Sales tax is not applicable on public records.
Standard-size Paper Copies _______ @ $0.10 page $ ___________
Standard-size Paper Copies-color_______ @ $0.25 page $ ___________
Large Map _______ @ $35.00 each $ ___________
Labels _______ @ $0.01 each $ ___________
CD ______M @ $1.00/meg $ ___________
Personnel Charges _______ @ $15.00/hour $ ___________
(Minimum charge $3.75)
Overhead Charges:
(20% of Total Personnel Charges) _______ $ ___________
Computer Resource Charges:
Mainframe _______ @ $17.50/hour $ ___________
(Minimum charge $4.38)
Client/Server _______ @ $1.50/hour $ ___________
(Minimum charge $.05)
PC/LAN _______ @ $.50/hour $ ___________
Programming Time _______ @ $26.00/hour $ ___________
(Minimum charge $6.50)
Postage/Shipping Charges Actual Cost $ ___________
Fax Charges:
Local _______ @ $.10/page $ ___________
Long Distance/Same Area Code _______ @ $.50/page $___________
Long Distance/Other Area Code _______ @ $1.00/page $___________
Other Charges (Description__________________________
________________________________________________
________________________________________________ Actual Cost $ ___________
TOTAL CHARGES $ ___________
Fields:
____ Name ____Separate First and Last Name
____ Permanent Address ____ Separate House # and Street
____ Mailing Address
____ Date of Birth (can provide year only)
____ Precinct
____ Certificate Number
g:forms, labels, and letters/data info request with treasurer stmt
“When you provide a check as payment, you
authorize us either to use information from
your check to make a one-time electronic
fund transfer from your account or to
process the payment as a check transaction.
For inquiries, please call (325)659-6520.”
Payable to/Pagar a:
Tom Green County
Attention: Elections
113 W. Beauregard Ave.
San Angelo, Texas 76903
AFFAOAVIT
PLEASE
BE
ADVISED
§ 18.067. Unlawful
Use
of
Master
File
Information
(a)
A person commits
an
offense
if
the person
uses
information
in
connection with advertising
or
promoting commercial products
or
services that the person knows
was
obtained under
Section 18.066.
(bl
An
offense under this section
is
a
Class
A misdemeanor.
Acts 1985,
69
th
leg., ch. 211. § 1, eff.
Jan.
1,
1986.
Amended by Acts 1997, 7
th
leg., ch. 864, § 13, eff. Sept.
1,
1997.
THE
STATE
OF
TEXAS
§
COUNTY
OF
TOM
GREEN
§
Before me,
the
undersigned authority, on this day personally appeared
____________________
-',
who being duly sworn, deposes and
says:
I do solemnly swear that the information obtained from the copy
of
the Voter Registration file will not
be
used
to
advertise
or
promote commercial products
or
services.
Signature
Sworn and subscribed before me, this
___
day
of
__________
-'
___
~
Notary Public
in
and
for
the State ofTexas
(SEAL)
Printed Name
of
Notary
My
commission expires:
_~
___________
_
G:/llo!er
request affitli!:vlt
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DATAINFORMATION REQUEST Tom Green County Attention: Elections 113 (Tom Green County)

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Completed 9 August 2020

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