Form Bw9-3 - Request For Peace Officer Confidentiality For Secretary Of State Or Local Voter Registration Office

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BW9-3
7/2011
REQUEST FOR PEACE OFFICER CONFIDENTIALITY
FOR SECRETARY OF STATE OR LOCAL VOTER REGISTRATION OFFICE
Pursuant to Section 552.1175 of the Government Code, if you are a peace officer, county jailer, current or former employee
of the Texas Department of Criminal Justice, or a commissioned security officer, you may request that information in the
voter registration records identifying your home address, home telephone number, social security number, or whether you
have relatives be restricted from public access. By completing and submitting this form to the County Voter Registrar’s
Office, you are requesting the confidentiality of the voter registration information as stated above. You must attach a
photocopy of documentation showing that you are eligible for confidentiality. If you want to rescind this confidentiality
request, you must do so in writing to the County Voter Registrar’s Office.
Name
Date of Birth
Step 1:
Identify Person
Residence Address (number and street)
Requesting
Confidentiality
City, State, Zip Code
VUID Number
County of Residence
Peace Officer (as defined by Article 2.12, Code of Criminal Procedure
Step 2:
);
Qualification
County Jailer (as defined by Section 1701.001, Occupations Code
(check one)
);
Current or former employee of the Texas Department of Criminal Justice (or
of the predecessor in function of the department or any division of the
department);
Commissioned Security Officer (as defined by Section 1702.002,
Occupations Code);
Employee of a District Attorney (DA), Criminal DA, or Municipal Attorney
whose jurisdiction includes any criminal law or child protective services
matters;
Officer/Employee of a community supervision and corrections department
established under Chapter 76 who perform a duty described by Section
76.004(b);
Criminal investigators of the United States as described by Article 2.122(a),
Code of Criminal Procedure; and
Police officers and inspectors of the United States Federal Protective
Service.
I have attached a photocopy of documentation showing evidence of my
Step 3:
qualification (proof of the qualification claimed above on Step 2).
Evidence of
Status
I certify that the information in this document and any information attached are true and
Step 4:
correct to the best of my knowledge and belief.
Sign and Date
Sign
Here► ___________________________________ Date ►___________________
Return this form to:
County Voter Registrar
Step 5:
____________________________________
Return this form
____________________________________
Or fax to _____________________________
For Office
Certificate # __________________
Documentation received?
Yes
No
Use Only
Confidentiality Approved?
Yes
No
Voter Reg. Dept. Signature ________________________________________ Date_________________
Comments: __________________________________________________________________________
If you make a false statement on this form, you could be found guilty of a Class A misdemeanor or a state jail felony under
Texas Penal Code Section 37.10.
By filing this document with the Secretary of State or the local voter registration office, information in the voter registration
records that identifies your home address, home telephone number, social security number, or whether you have relatives
will be restricted from public access until you rescind the request in writing. However, pursuant to Attorney General Open
Records Decision No. 678, the information will be available for the official use of the local voter registration, the state, and
political subdivisions of the state.

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