Pursuant to Section VI(B)(5) of Arkansas Supreme Court Administrative Order 19
To support my request for a compiled extract of court data, I hereby provide the following information
and declare, under penalty of perjury:
What is the aim of the project (optional)?
I am requesting information on cases excluded from public access under Section VII of Administrative
Order 19. Explain In detail why case information excluded from public access is needed and how the
information will be used:
I am requesting the identification of specific individuals; the information of specific individuals is
essential to the purpose of the inquiry; and the request is made for scholarly, journalistic, political,
governmental, research, evaluation, or statistical purpose. Explain in detail why the identification of
specific individuals is essential to the purpose of the inquiry and how the information will be used:
Case or person specific information will be provided to others. Please explain:
The information will be linked to other databases. Please explain how and for what purpose:
Please describe the methods by which the confidential information or individual identifying
information will be protected from unauthorized disclosure:
If requesting individually identifiable data for research purposes:
I have received IRB approval for human subject research for this research project. The IRB contact for
my organization is:
Printed Name
Company Name and Address
State of
County of
Subscribed and sworn before me
Notary Public Signature
My commission expires: