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Date

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Date

2

News Organization Name

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News Organization Name

3

Name (First and Last) 

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Name (First and Last)

4

Email

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Email

5

Phone Number

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Phone Numberext.

6

Mailing Address (Street Name & House Number, City and Zip Code)

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Mailing Address (Street Name & House Number, City and Zip Code)

7

Under the provisions of A.R.S. § 39-121, it is requested that the following records be released: (Please be specific)

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Under the provisions of A.R.S. § 39-121, it is requested that the following records be released: (Please be specific)

8

 Indicate whether the record(s) is to be used for (see definition in Information and Instruction Sheet):

Indicate whether the record(s) is to be used for (see definition in Information and Instruction Sheet):

Commercial Purpose

Non-Commercial Purpose

9

 These records will be used for the following purpose(s): (Please be specific. Please note that there are penalties associated with either using public records or allowing them to be used for a commercial purpose without declaring such intent on this request.)

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These records will be used for the following purpose(s): (Please be specific. Please note that there are penalties associated with either using public records or allowing them to be used for a commercial purpose without declaring such intent on this request.)

10

 I declare that I have read the Information and Instruction Sheet (or A.R.S. § 39-121.03 itself) and understand the contents herein. Under penalty of perjury, I declare the information I have provided is true and correct and that the records received pursuant to this request will not be used for a purpose other than has been identified herein.

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Please check here to indicate "yes" to the declaration.

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