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Public Records Reproduction Request - Arizona
| Public Records Reproduction Request Form. This is a Arizona form and can be used in Securities Blue Sky Secretary Of State . |
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THIS DOCUMENT IS AVAILABLE IN ALTERNATIVE FORMATS BY CONTACTING Yvonne McFarlin, EXECUTIVE ASSISTANT TO THE EXECUTIVE SECRETARY, VOICE PHONE NUMBER 602/542-3931, E-MAIL YMcFarlin@CC.STATE.AZ.US . MAIL OR RETURN TO: INTERNAL USE ONLY Please complete and return within 10 days c/o INFORMATION OFFICER INFORMATION OFFICER along with Securities Division Documents reproduction fee of $ __________________ Arizona Corporation (payable to AZ Corporation Commission) Commission Picked up Date __________ 1300 W. Washington - Third Floor Sent Date __________ Phoenix, Arizona 85007 Initials ________ PUBLIC RECORDS REPRODUCTION REQUEST (Pursuant to ARS 39-121.03) Your full name: Your title: Full name, address and phone number of the firm you represent: ( ) (Name of Firm) (Business Telephone Number) (Date) (Address) (City) (State) (Zip) Your Signature Indicate the records you wish to have copied or reproduced: Indicate (X) whether these records are to be used for: Commercial Purpose * Non-commercial Purpose (See below and back of form) (Note that obtaining public records under false pretenses may subject requester to penalties) To help you determine whether you are making this request for a "commercial purpose " as defined in Arizona Revised Statutes Section 39-121.03, that definition appears below. Commercial purpose means the use of a public record for the purpose of sale or resale or for the purpose of producing a document containing all or part of the copy, printout or photograph for sale or the obtaining of names and addresses from public records for the purpose of solicitation or the sale of names and addresses to another 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 the public record. Commercial purpose does not mean the use of a public record as evidence or as research for evidence in an action in any judicial or quasi-judicial body. ARS 39-121.03(D). (over) REV. 09/2003 <<<<<<<<<********>>>>>>>>>>>>> 2*If you are requesting the public records for a COMMERCIAL PURPOSE, please read all information on this form and sign the statement below before a Notary Public. Pursuant to ARS 39 -121.03, any person requesting copies, printouts or photographs of public records for a commercial purpose must provide a statement setting forth the commercial purpose for which the records/reproductions will be used. A person providing a statement setting forth the commercial purpose for which the reproductions will be used may be furnished such reproductions for a charge reflecting the following: (1) a portion of the cost to the state for obtaining the documents or records to be reproduced, (2) a reasonable fee covering the cost of time, materials, equipment, and personnel in producing the reproduction, and (3) the value of the reproduction on the commercial market as determined by the state. If the custodian of a public record determines that the stated commercial purpose of a reproduction is a misuse of public records or an abuse of the right to receive them, the custodian may refuse the request for reproduction of the records for the stated commercial purpose and must apply to the Governor for an Executive Order prohibiting the furnishing of the reproductions for the commercial purpose stated. If an Executive Order is not issued within thirty (30) days of the custodians application, the requesting party will be furnished such reproductions for the commercial purpose set forth in his or her statement upon payment of the appropriate fee. 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 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 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 that would have been charged for the public record had the commercial purpose been stated plus costs and reasonable attorneys 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. State of ) County of ) STATEMENT This document represents the statement of _______________________________ submitted to the Securities Division of the ARIZONA CORPORATION COMMISSION (the "Custodian") requesting that the Custodian provide a copy or other reproduction of the public records specified on the reverse side of this form for the following specific commercial purpose: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ _____________________________________________________. I declare that I have read all information on this form (or ARS 39-121.03 itself) and understand the contents therein. I further declare that I understand I am being sold the use of the public records referred to herein and am prohibited from using them for any reason other than as stated above, and that at all times these records remain the property of the Custodian and are subject to return upon demand. I state, under penalty of perjury, that the foregoing is correct and true. _ _____________________________________________ (Date) (Signature of Party Requesting Records) SUBSCRIBED AND SWORN TO before me this _____ day of _________________, 20__. ____________________________________ (Notary Public) My commission expires: REV. 09/2003
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