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Affidavit To Restrict Public Access To Address And Telephone Numbers In Public Records (Person Protected By Order Or Injunction) Form. This is a Arizona form and can be use in Personal Information Protection Statewide.
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Tags: Affidavit To Restrict Public Access To Address And Telephone Numbers In Public Records (Person Protected By Order Or Injunction), Arizona Statewide, Personal Information Protection
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 ONLY BY PERSONS PROTECTED BY AN ORDER OF PROTECTION OR
INJUNCTION AGAINST HARASSMENT
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 10 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 12 that
appear in Motor Vehicle Division records. I understand that the order to seal MVD records has
no automatic expiration.
3. I am a person protected by an order of protection or injunction against harassment. In support of
my claim, I have attached to this affidavit a true and correct copy of the order of protection or
injunction against harassment naming me as a protected person.
Affidavit for use by protected persons
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4. I believe that my life or safety or that of my family or other persons living at my primary
residence is in danger of physical harm for the following reasons:
______________________________________________________________________________
______________________________________________________________________________
5. (Optional – complete this item ONLY if you need immediate record protection) I request
immediate action for the following reasons:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________
6. Restricting public access to the records I selected in item 2 above will serve to reduce the danger
I described in item 4 for the following reasons:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
7. My primary residential address and telephone number are:
_______________________________________________________________________________
Street Address
City
State
ZIP
Phone Number
8. (For County Recorder, Assessor and/or Treasurer records only) The identifying numbers
relating to my primary residential address are:
Parcel Number: __________________________ Book & Map Number:___________________
Full Legal Description: __________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Affidavit for use by protected persons
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9. (For County Recorder, Assessor and/or Treasurer records only) The document locator number
and date of recordation of each document 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 number
Date of recordation
_______________________________________________________________________________________
Document locator number
Date of recordation
______________________________________________________________________________________
Document locator number
Date of recordation
10. (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
Month/Day/Year of Birth
_________________________________________________________________________________[ ] add to PEVL
Full legal name
Affidavit for use by protected persons
Month/Day/Year of Birth
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11. (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 or State I.D. Number
12. (For protecting other household members’ MVD records only) The following individuals and/or
entities (such as partnerships or 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 are peace officers):
_________________________________________________________________________________________________________
Full legal name
Month/Day/Year of Birth
Driver’s License/State I.D. Number
_________________________________________________________________________________________________________
Full legal name
Month/Day/Year of Birth
Driver’s License/State I.D. Number
_________________________________________________________________________________________________________
Full legal name
Month/Day/Year of Birth
Driver’s License/State I.D. Number
_________________________________________________________________________________________________________
Full legal name
Month/Day/Year of Birth
Driver’s License/State I.D. Number
_________________________________________________________________________________________________________
Full legal name
Month/Day/Year of Birth
Driver’s License/State I.D. Number
On the basis of the facts set forth herein, I respectfully request the court to order the sealing of the
information and records identified by me in item 2 above.
___________________________
_____________________________________
Date
Affiant’s signature
State of Arizona
)
) ss.
)
County of _______________________________________)
Subscribed and sworn to (or affirmed) before me on ___________________________________
My commission expires:______________
_________________________________________
Notary Public
Affidavit for use by protected persons
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