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Affidavit Attesting To The Use Of Public Records (KSA 45-230) K-WC-308 - Kansas

Affidavit Attesting To The Use Of Public Records (KSA 45-230) Form. This is a Kansas form and can be used in Workers Compensation .
 Fillable pdf Last Modified 8/6/2014
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KANSAS DEPARTMENT OF LABOR www.dol.ks.gov AFFIDAVIT ATTESTING TO THE USE OF PUBLIC RECORDS IN COMPLIANCE WITH K.S.A. 45-230, AS AMENDED K-WC 308 (Rev. 2-13) I request that the Kansas Department of Labor Division of Workers Compensation provide me with a list of names, addresses and/or other contact information of persons, businesses or organizations taken from or otherwise contained in public records subject to the Kansas Open Records Act (KORA), K.S.A. 45-215 et seq. Pursuant to K.S.A. 45-220(c)(2), and amendments thereto, I hereby affirmatively state that I have read, understand and agree to comply with all the provisions of K.S.A. 45-230, as amended, and I do hereby promise and state that I will not: (A) use any list of names or addresses contained in or derived from the records or information for the purpose of selling or offering for sale any property or service to any person listed or to any person who resides at any address listed; or (B) sell, give or otherwise make available to any person any list of names or addresses contained in or derived from the records or information for the purpose of allowing that person to sell or offer for sale any property or service to any person listed or to any person who resides at any address listed. Information requested: ____________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________ ___________________________________________________________ Signature Date ___________________________________________________________ ___________________________________________________________ Name (please print) Title Mailing address (Street or PO Box) City, State, ZIP Phone Email ___________________________________________________________ ___________________________________________________________ ) ___________________________________________________________ ( ___________________________________________________________ Company name ___________________________________________________________ State of Kansas, County of ___________________________ BE IT REMEMBERED, that on this ____________day of ___________________, 20____, before me, the undersigned, a Notary Public in and for said county and state, came the above named individual, to me personally known to be the same person who signed, acknowledged and agreed to the foregoing instrument of writing and duly acknowledged that he understood and executed the same as of the date above written. Notary Public ______________________________________ Commission expires _________________________________ SEAL DIVISION OF WORKERS COMPENSATION 401 SW Topeka Blvd., Suite 2, Topeka, KS 66603-3105 · Phone (785) 296-4000 · Fax (785) 296-0839 American LegalNet, Inc. www.FormsWorkFlow.com
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