Treasurer Request for Records – Certification

Certification

I , as the requestor of the records described in (required)

the letter, form or email sent previously
the section below (“Description of Records Requested”)

hereby state that consistent with KSA 45-230 I do 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 for 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.

I declare or certify under penalty of perjury under the laws of the State of Kansas that the foregoing is true and correct.

Signature of Requestor

Contact Information

Name (required)

Mailing Address (required)

City (required)

ZIP Code (required)

Phone Number

Email Address

Request Details

Description of Records Requested (required)

Security Verification

ReCaptcha (required)