Fillable VR ADCVI (Harris County Tax Office)

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VR ADCVI (Harris County Tax Office)

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VR-ADCVI www.hctax.net Rev 02/14 v.2
AUTHORIZATION TO DISCLOSE CONFIDENTIAL VOTER INFORMATION
* This Authorization to Disclose Confidential Voter Information is valid for one (1)
year unless otherwise specified. Authorization is effective until: _______________, 20______.
** Representative shall be required to present a valid state issued driver’s license or
personal identification card or federal identification to receive requested voter
registration records of the voter listed above.
I request that the Harris County Tax Office release my voter registration records,
including information that is considered confidential by law, to the Representative
named below:
Name of Voter _________________________________________________________________________________
Address _________________________________________________________________________________________
City ________________________ State ___________ Zip Code _______________________________________
Telephone Number _________________________ Date of Birth ________________________________
Voter Registration Certificate Number ____________________________________________________
Signature of Voter _____________________________________________________________________________
*Date ____________________________________________________________________________________________
**Representative Name_________________________________________________________________________
Address ___________________________________________________________________________________________
City __________________________________ State __________________ Zip Code _______________________
Telephone Number ______________________________ (cellular) _________________________________
ANN HARRIS BENNETT
Tax Assessor-Collector & Voter Registrar
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VR ADCVI (Harris County Tax Office)

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Completed 18 July 2020

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