Open Records Request Form - Seward County printable pdf download

Open Records Request Form - Seward County

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=s Name:____________________________________________

(Please Print)

Address:____________________________________________________Phone:_______________

Applicant=s 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 Services

_______________________

TOTAL

Signature of Technician__________________

Open Records Request Form - Seward County