Affidavit To Restrict Public Access To Address And Telephone (Eligible Public Employees) {AOC CRDPE1F}

AFFIDAVIT IN SUPPORT OF APPLICATION TO RESTRICT PUBLIC ACCESS TO ADDRESS AND TELEPHONE NUMBERS IN SPECIFIED PUBLIC RECORDS PURSUANT TO A.R.S. §§11-483, 11-484, 12-290, 16-153, AND/OR 28-454 (FOR USE BY THOSE LISTED IN ITEM 3 ONLY) PLEASE READ THE INSTRUCTIONS BEFORE COMPLETING THIS FORM AND PRINT ALL REQUIRED INFORMATION IN BLACK INK 1. I, Full legal name , make the following statements under oath: 2. I submit this affidavit pursuant to (check only the types of records you are seeking to protect): [ ] (For County Recorder records) A.R.S. §11-483, and request that the court order sealed for five years my residential address and phone number appearing in instruments and writings recorded by the County Recorder and the unique identifiers and recording dates contained in indexes of recorded instruments maintained by the County Recorder. [ ] (For County Assessor records) A.R.S. §11-484, and request that the court order sealed for five years my residential address and phone number appearing in instruments, writings and information maintained by the County Assessor. [ ] (For County Treasurer records) A.R.S. §11-484, and request that the court order sealed for five years my residential address and phone number appearing in instruments, writings and information maintained by the County Treasurer. [ ] (For voter registration records) A.R.S. §16-153, and request that the court order sealed for five years my residential address and phone number and voting precinct number and those of any individuals identified in item 12 below that appear in voter registration records. [ ] (For Motor Vehicle Division records) A.R.S. §28-454, and request that the court order sealed my residential address and phone number and those of any individuals identified in item 14 below that appear in Motor Vehicle Division records. I understand that the order to seal MVD records has no automatic expiration. Address Confidentiality Program Participant records are not eligible for sealing under this provision. 3. I am eligible because I am a(n) (check the description that applies to you): [ ] Address Confidentiality Program Participant [ ] Border Patrol Agent [ ] Code Enforcement Officer [ ] Commissioner [ ] Corrections or Detention Officer [ ] Corrections Support Staff [ ] Department of Child Safety Employee [ ] Executive Clemency Board Member [ ] Firefighter assigned to the Department of Public Safety Counterterrorism Center [ ] Former Public Official [ ] Judge or Former Judge [ ] Justice [ ] Law Enforcement Support Staff [ ] National Guard Member supporting a Law Enforcement Agency [ ] Peace Officer or Peace Officer's Spouse [ ] Probation Officer [ ] Prosecutor [ ] Public Defender [ ] Spouse or minor child of a Deceased Peace Officer American LegalNet, Inc. www.FormsWorkFlow.com as provided in A.R.S. §§11-483 (N), -484(K), 12-290, 16-153(K), or 28-454(K). Arizona Supreme Court Affidavit for use by public employees/officials Page 1 of 4 AOC CRDPE1F-040115 4. I am employed by or was formerly employed by (organization name): ______________________________________________________________________________ 5. My current job title and duties include: 6. I believe that my life or safety, or that of my family or other persons living at my residence, is in danger of physical harm for the following reasons: 7. (Optional ­ complete this item ONLY if you need immediate record protection) I request immediate action for the following reasons: 8. Restricting public access to the records I selected in item 2 above will serve to reduce the danger I described in item 6 for the following reasons: 9. My primary residential address and telephone number are: Street Address City State ZIP Phone Number Arizona Supreme Court Affidavit for use by public employees/officials Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com AOC CRDPE1F-040115 10. (For County Recorder/Assessor/Treasurer records only) The identifying numbers relating to my primary residential address are: Parcel Number: Full Legal Description: Book & Map Number: 11. (For County Recorder/Assessor/Treasurer records only) The document locator number and date of recordation of each instrument for which I request public access restriction pursuant to A.R.S. §§11-483 and/or -484 are as follows. I have attached a copy of pages from each document that show the document locator number, and either my full legal name and primary residential address or my full legal name and telephone number: Document locator number Date of recordation Document locator number Date of recordation Document locator number Date of recordation Document locator number Date of recordation Document locator number Date of recordation Document locator number Date of recordation 12. (For voter registration records only -- see the instruction sheet for more information) The following are the names and birth dates for each registered voter who resides with me and whose voter registration records should also be redacted. I have informed these individuals that I have applied to have their addresses protected and that they will need to vote by mail in the future in order to keep this information out of the public record. I have also informed them that if they vote in-person at a polling location, they will be required to vote a provisional ballot. I have checked the box for each voter who is requesting to be added to the Permanent Early Voting List (PEVL) to automatically receive an early ballot by mail, and I have attached their completed voter registration forms so they can be added to the PEVL. [ ] add to PEVL Full legal name Month/Day/Year of Birth [ ] add to PEVL Full legal name Month/Day/Year of Birth [ ] add to PEVL Full legal name Month/Day/Year of Birth [ ] add to PEVL Full legal name Month/Day/Year of Birth [ ] add to PEVL Full legal name Arizona Supreme Court Affidavit for use by public employees/officials Month/Day/Year of Birth Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com AOC CRDPE1F-040115 13. (For your MVD records) My name, birth date and driver's license or state identification number are: Full legal name Month/Day/Year of Birth Driver's License /State I.D. Number 14. (For protecting other household members' MVD records only) The following individuals and/or entities (such as partnerships, corporations) have MVD records that display my primary residential address and/or telephone number and therefore should also be redacted (see the instruction sheet regarding household members who ar