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REQUEST FOR PUBLIC RECORD(S)

  1. la paz seal

  2. La Paz County Community Development

    1112 Joshua Avenue, suite 202 Parker, AZ. 85344 PH: (928) 669-6138 TDD: (928) 669-8400 FAX: (928) 669-5503

  3. REQUEST FOR PUBLIC RECORD(s)

  4. REQUESTER'S INFORMATION:

  5. PUBLIC RECORD(s) REQUESTED

  6. RECORDS ARE .25 CENTS PER PAGE AND IF FOR A COMMERCIAL PURPOSE AND ADDITIONAL $10 PER HOUR PER PERSON FOR TIME EXPENDED IN SEARCHING FOR AND RETRIEVING THE RECORDS REQUESTED.

  7. I declare that I have read A.R.S. §39-121.03 (which includes the definition of "commercial purpose") and 39-161 which sets forth the criminal penalty for making false statement on this request as they appear on the reverse side of this request. I further declare under penalty of law that the foregoing is true and correct.

  8. 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.

  9. FOR OFFICE USE ONLY

  10. Leave This Blank:

  11. This field is not part of the form submission.