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Affidavit To Restrict Public Access To Address And Telephone (Eligible Public Employees) 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 (Eligible Public Employees), 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 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
[ ] Justice
[ ] Code Enforcement Officer
[ ] Law enforcement support staff person
[ ] Commissioner
[ ] Corrections or detention officer (adult or juvenile)
[ ] National Guard member supporting a law
enforcement agency
[ ] Peace officer
[ ] Corrections support staff person
[ ] Probation officer
[ ] Executive Clemency Board member
[ ] Prosecutor
[ ] Firefighter assigned to the Department of Public
Safety Counterterrorism Center
[ ] Judge
[ ] 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
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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
Affidavit for use by public employees/officials
City
State
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ZIP
Phone Number
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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 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
Affidavit for use by public employees/officials
Month/Day/Year of Birth
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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 are peace officers):
_____________________________________________________________________________________________
Full legal name
Month/Day/Year of Birth
Driver’s License or State I.D. Number
_____________________________________________________________________________________________
Full legal name
Month/Day/Year of Birth
Driver’s License or State I.D. Number
_____________________________________________________________________________________________
Full legal name
Month/Day/Year of Birth
Driver’s License or State I.D. Number
_____________________________________________________________________________________________
Full legal name
Month/Day/Year of Birth
Driver’s License or State I.D. Number
_____________________________________________________________________________________________
Full legal name
Month/Day/Year of Birth
Driver’s License or 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 public employees/officials
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