Request should be directed to the sp
ecific department to which the information is being requested from
Caution: Arizona Revised Statutes §39-121.03(C) provides:
“A person who obtains public records for a commercial purpose without indicating the commercial purpose or who obtains a public
record for a noncommercial purpose and uses or knowingly allows the use of such public record for a commercial purpose or who
obtains a public record for a commercial purpose and uses or knowingly allows the use of such public record for a different commercial
purpose or who obtains a public record from anyone other than the custodian of such records and uses them for a commercial purpose
shall in addition to other penalties be liable to the state or the political subdivision from which the public record was obtained for
damages in the amount of three times the amount which would have been charged for the public record had the commercial purpose
been stated plus costs and reasonable attorney’s fees or shall be liable to the state or the political subdivision for the amount of three
times the actual damages if it can be shown that the public record would not have been provided had the commercial purpose of actual
use been stated at the time of obtaining the records.”
A commercial purpose is defined by Arizona Statute as the use of a public record for the purpos
e of:
the sale or resale or for the purpose of producing a document containing all or part of the copy, printout, or photograph for sale, or
obtaining of names and addresses from such public records for the purpose of solicitation, or
for any purpose in which the purchaser can reasonably anticipate the receipt of monetary gain from the direct or indirect use of
such public record.
This form is required to be filed by commercial users pursuant to A.R.S. §3
9-121.03(C).
I, ___________________________________, am the _____________________________________of
(Print name) (Print Title)
______________________________________, located at _______________________________, which
(Print Company Name) (Address)
is engaged in the busin
ess of _______________________________. I am requesting the following information:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
(State information being requested. The request must be legible and specific. Use back or additional sheets if needed)
Email address (optional)
________________________________ Contact phone:______________________________________
I do hereby confirm that the public re
cords which I have requested are for the following purpose:
(State use of public records. The request must be legible and specific. Use back or additional sheets if needed)
which I can reas
onably anticipate will result in the monthly amount of $_______________ from the direct/ indirect use of these records.
_________________________________________ _________________________
Signature Date
_________________________________________ _________________________
Notary Public Date Commission Expires
Office use only Paper copies Electronic copies
Number of pages: ___________ CD/Tape recording: ___________
Paper size:_________________ Other: ______________________ Total cost: ____________
Date received: ______________ Date completed: _____________ Employee initial_________
Verified Statement of Commercial Purpose
Public Data Request
click to sign
signature
click to edit
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