2. REQUEST FOR PUBLIC RECORDS
4. 
6. REQUESTOR'S INFORMATION
8. Name
9. Email Address
11. Address
12. Phone Number
14. Representing
16. Address
17. Phone Number
19. PUBLIC RECORD(S) REQUESTED
21. Commercial

    1. Yes
    2. No

23. WARNING: Arizona Revised Statutes §39-121.03(C) provides:

    A “Commercial Purpose” means the use of a public record for the purpose of sale or resale including any of the following:

    • Producing a document containing all or part of the copy, printout or photograph for sale, or
    • Obtaining of names and addresses from such public records for the purpose of solicitation or for creating a list for resale, or
    • For any purpose in which the purchaser can reasonably anticipate the receipt of monetary gain from the direct or indirect use of such public records. (A.R.S.§39-121.03(D)).

    A person who obtains public records for commercial purpose without indicating the commercial purpose or who obtains a public record for a non-commercial purpose and uses or knowingly allows the uses of such public record for a commercial purpose or who obtains a public record for a commercial purpose and uses or knowingly allows the use of such public record for a different commercial purpose shall in addition to other penalties be liable to the state or the political subdivision from which the public record was obtained for damages in the amount of three times the amount which would have been charged for the public record had the commercial purpose been stated plus costs and reasonable attorney’s fees or shall be liable to the state or political subdivision for the amount of three times the actual damages if it can be shown that the public record would have not been provided had the commercial purpose of actual use been stated at the time of obtaining the records.

25. Specify the exact record(s) requested
27. Number of copies
29. State the exact use of requested public records.
31. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
33. Signature of Requestor
34. Date
    Date
36. Disclaimer Indemnification

    Requester/Purchaser understands that La Paz County does not guarantee the accuracy of the data and information requested and hereby expressly disclaims any responsibility for the truth, lack of truth, validity, invalidity, accuracy, inaccuracy of any said data and information. Requester/Purchaser accepts responsibility for Requester/Purchaser’s unauthorized use or transmission of any such data or information in its actual or altered form.

Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit Submit and Print

* indicates a required field