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Verified Statement of NON-COMMERCIAL Purpose Public Record Request

  1. I am requesting to:*
  2. State record being requested.  Please be specific.

  3. I verify that the record(s) will not be used for a commercial purpose.  Commercial Purpose is defined as: “the use of a public record for the purpose of sale or resale or for the purpose of producing a document containing all or part of the copy, printout or photograph for sale or the obtaining of names and addresses from such public record for the purpose of solicitation 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.”   

    I certify that all information provided is true and correct.  I agree to pay applicable fees for these records. I also agree that the public records will not be transmitted or resold to any other person or entity without specific authorization from the County’s record custodian.  I agree to delete all data acquired via this request from my databases and all other electronic media forms upon completion of the purpose or use for which this request is made.  I agree not to hold Graham County liable for any inaccurate or incomplete information I may receive. (See Disclaimer below.)

  4. 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.
  6. An individual who knowingly falsifies his certificate for a document under these provisions is guilty of a class 6 felony. Further, any person who obtains a public record for a noncommercial purpose and uses or knowingly uses the use 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 or who obtains a public record from anyone other than the custodian of such records and uses them for a commercial purpose shall be liable to the state or the political subdivision for the amount of three times the actual damages if it can be shown that the public record would not have been provided had the commercial purpose or actual use been stated at the time of obtaining the records.


    Requester understands and agrees that Graham 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, or inaccuracy of said data and information. Requester agrees to indemnify Graham County, its officers and employees from any liability which may arise from the Requester’s unauthorized use or transmission of any such data or information in its actual or altered form.

    1. Please re-enter your email address below and make sure the "Receive an email copy of this form" box is checked. It's important that you receive a confirmation email after you hit the "Submit" or "Submit and Print" button below. Thank you!

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