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Affidavit To Restrict Public Access To Address And Telephone (Eligible Public Employees) - Arizona
| Affidavit To Restrict Public Access To Address And Telephone (Eligible Public Employees) Form. This is a Arizona form and can be used in Personal Information Protection Statewide . |
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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, 16-153, AND/OR 28-454 (FOR USE BY PUBLIC EMPLOYEES OR OFFICIALS LISTED IN ITEM 3 ONLY) PLEASE READ THE INSTRUCTIONS BEFORE COMPLETING THIS FORM AND PRINT ALL REQUIRED INFORMATION IN BLACK INK 1. I, _________________________________________________________________, make the Full legal name 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. 3. I am employed as a (check the description that applies to you): [ ] Border Patrol Agent [ ] Code Enforcement Officer [ ] Commissioner [ ] Corrections or detention officer (adult or juvenile) [ ] Corrections support staff person [ ] Executive Clemency Board member [ ] Firefighter assigned to the Department of Public Safety Counterterrorism Center [ ] Judge [ ] Justice [ ] Law enforcement support staff person [ ] National Guard member supporting a law enforcement agency [ ] Peace officer [ ] Probation officer [ ] Prosecutor [ ] Public defender as provided in A.R.S. §11-483 (N), §11-484(K), §16-153(K), or §28-454(K). Affidavit for use by public employees/officials Page 1 of 4 AOC ver 6/2011 American LegalNet, Inc. www.FormsWorkFlow.com 4. I am 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 Affidavit for use by public employees/officials Page 2 of 4 AOC ver 6/2011 American LegalNet, Inc. www.FormsWorkFlow.com 10. (For County Recorder/Assessor/Treasurer records only) The identifying numbers relating to my primary residential address are: Parcel Number: __________________________ Book & Map Number:___________________ Full Legal Description: __________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 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 §11-484 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
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