REQUEST PURSUANT TO KANSAS OPEN RECORDS ACT READ CAREFULLY BEFORE SIGNING “No person shall knowingly sell, give or receive, for the purpose of selling or offering for sale any property or service to persons listed therein, any list of names and addresses contained in or derived from public records...” K.S.A. 45-230(a). Violation of this law may subject the violator to a civil penalty of $500.00 for each violation. By signing below, I acknowledge that I am aware of and understand K.S.A. 45-230. Pursuant to the Kansas Open Records Act, I request the following records (Please specify): Requester Name:____________________________________________ (Please Print) Address:____________________________________________________Phone:_______________ Requester Signature:_____________________________________ Date Submitted:___________ By signing this request form, the requester makes the following certification pursuant to K.S.A. 45-220(c)(2): “the requester does not intend to, and 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 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.” FOR OFFICE USE ONLY: Form of Identification ____________________________________________________ Request: [ ] Granted [ ] Denied [ ] Delayed Fees Charged: ________________ Copies ________________ Staff Time ________________ Computer Service ________________ Total SIGNATURE _________________________________ Date____________________________ Director, Department of Records & Tax Administration American LegalNet, Inc. www.USCourtForms.com