Form ADR005 "Public Records Reproduction Request" - Arizona

What Is Form ADR005?

This is a legal form that was released by the Arizona Department of Gaming - Division of Racing - a government authority operating within Arizona. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 6, 2016;
  • The latest edition provided by the Arizona Department of Gaming - Division of Racing;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form ADR005 by clicking the link below or browse more documents and templates provided by the Arizona Department of Gaming - Division of Racing.

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Download Form ADR005 "Public Records Reproduction Request" - Arizona

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DEPARTMENT OF GAMING
RACING DIVISION
P
R
R
R
F
UBLIC
ECORDS
EPRODUCTION
EQUEST
ORM
I
I
S
NFORMATION AND
NSTRUCTION
HEET
Requesting Party: Please read and note the following information and instructions.
Pursuant to A.R.S. § 39-121.03, a person requesting copies, printouts or photographs of public records shall, upon making
a request, provide a
setting forth the commercial purpose, if any, for which the copies, printouts or
CERTIFIED STATEMENT
photographs will be used.
A person stating that the reproductions will not be used for a commercial purpose will be furnished such reproductions at a
reasonable fee, not exceeding a commercial rate for like services. A person providing a certified statement setting forth
the commercial purpose for which the reproduction will be used, may be furnished such reproductions by the custodian of
records after having received approval from the Director or Deputy Director, as determined on a case by case basis.
Charges shall be based on the following:
1. A portion of the cost to the State for obtaining the documents or records to be reproduced;
2. A reasonable fee covering the cost of time, equipment and personnel in making the
reproduction, and;
3. The value of reproduction on the commercial market.
If the custodian of a public record believes that the commercial purpose of a reproduction is a misuse of public records or
an abuse of the right to receive them, he or she may refuse a request for reproduction of such records for said commercial
purpose and may request the Governor to prohibit the furnishing of reproductions for such commercial purposes by
Executive Order. If an Executive Order is not issued within thirty (30) days of the custodian's application, the requesting
party shall be furnished such reproductions for the commercial purpose set forth in his or her certified statement upon
payment of the fee determined pursuant to the above guidelines.
"Commercial purpose" is broadly defined by statute as "any purpose in which the purchaser can reasonably anticipate the
receipt of monetary gain from the direct or indirect use of such public record."
A.R.S. § 39-121.03(D).
"Commercial purpose" includes copies of records for sale or resale and copies of printouts of names and addresses for
purpose of solicitation of business.
IMPORTANT: A.R.S. § 39-121.03(C) and (D) state:
A person who obtains a public record for a commercial purpose without indicating the commercial purpose
or who obtains a public record for a noncommercial purpose and uses or knowingly allows 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 it for a 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
fees or 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 of actual use been stated at the time of obtaining the records.
For the purposes of this section, “commercial purpose” means 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 public records for the purpose of
solicitation or the sale of names and addresses to another 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 the public record. Commercial purpose does not mean the use of a public record as
evidence or as research for evidence in an action in any judicial or quasi-judicial body.
ADR005 (Revised 10/06/2016)
Public Records Reproduction Request Form/Information and Instruction Sheet
Page 1 of 2
DEPARTMENT OF GAMING
RACING DIVISION
P
R
R
R
F
UBLIC
ECORDS
EPRODUCTION
EQUEST
ORM
I
I
S
NFORMATION AND
NSTRUCTION
HEET
Requesting Party: Please read and note the following information and instructions.
Pursuant to A.R.S. § 39-121.03, a person requesting copies, printouts or photographs of public records shall, upon making
a request, provide a
setting forth the commercial purpose, if any, for which the copies, printouts or
CERTIFIED STATEMENT
photographs will be used.
A person stating that the reproductions will not be used for a commercial purpose will be furnished such reproductions at a
reasonable fee, not exceeding a commercial rate for like services. A person providing a certified statement setting forth
the commercial purpose for which the reproduction will be used, may be furnished such reproductions by the custodian of
records after having received approval from the Director or Deputy Director, as determined on a case by case basis.
Charges shall be based on the following:
1. A portion of the cost to the State for obtaining the documents or records to be reproduced;
2. A reasonable fee covering the cost of time, equipment and personnel in making the
reproduction, and;
3. The value of reproduction on the commercial market.
If the custodian of a public record believes that the commercial purpose of a reproduction is a misuse of public records or
an abuse of the right to receive them, he or she may refuse a request for reproduction of such records for said commercial
purpose and may request the Governor to prohibit the furnishing of reproductions for such commercial purposes by
Executive Order. If an Executive Order is not issued within thirty (30) days of the custodian's application, the requesting
party shall be furnished such reproductions for the commercial purpose set forth in his or her certified statement upon
payment of the fee determined pursuant to the above guidelines.
"Commercial purpose" is broadly defined by statute as "any purpose in which the purchaser can reasonably anticipate the
receipt of monetary gain from the direct or indirect use of such public record."
A.R.S. § 39-121.03(D).
"Commercial purpose" includes copies of records for sale or resale and copies of printouts of names and addresses for
purpose of solicitation of business.
IMPORTANT: A.R.S. § 39-121.03(C) and (D) state:
A person who obtains a public record for a commercial purpose without indicating the commercial purpose
or who obtains a public record for a noncommercial purpose and uses or knowingly allows 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 it for a 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
fees or 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 of actual use been stated at the time of obtaining the records.
For the purposes of this section, “commercial purpose” means 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 public records for the purpose of
solicitation or the sale of names and addresses to another 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 the public record. Commercial purpose does not mean the use of a public record as
evidence or as research for evidence in an action in any judicial or quasi-judicial body.
ADR005 (Revised 10/06/2016)
Public Records Reproduction Request Form/Information and Instruction Sheet
Page 1 of 2
P
R
R
R
UBLIC
ECORDS
EPRODUCTION
EQUEST
Requesting Party:
Date:
Please Print
Telephone No. _________________ Fax No. _____________________ Email Address: __________________________
Address: _________________________________________________________________________________________
Description of Public Records requested:
Indicate whether the records are to be used for:
Non-Commercial Purposes
Commercial Purposes
If the records are to be used for commercial purposes, specifically state those purposes:
C
S
ERTIFIED
TATEMENT
I, the requesting party, declare that I have read the information and instruction sheet accompanying this form and understand the
contents therein. I further declare that I have reviewed the definition of commercial and non-commercial purposes; that I understand
the cost of a copy reproduction is $1.00 for the first 5 pages then $0.50/page for each additional page, or the cost incurred by the
Department for replication of oversized documents; and that the cost of replication must be paid prior to replication. I further declare
that such copies or reproductions will not be used directly or indirectly for a different purpose other than described above.
I further declare under penalty of perjury that the foregoing is correct and true.
Date:
Signature of Requesting Party
F
O
U
O
OR
FFICE
SE
NLY
A
:
PPROVALS
Director
Approved / Denied (circle one) Date
R
D
:
Misuse of Public Records or
Abuse of the Right to Receive Public Records
EASON
ENIED
Request Made to Governor for Executive Order
Date
Executive Order Received within 30 days
Date Received
No Executive Order Received - Reproductions Furnished
Date
Custodian of Records:
Title
• First 5 pages @ $1.00 per 8.5x11” page
• Audio CDs – $5 per CD
Cost of Reproduction:
• 50¢ each for all additional 8.5x11” pages
• Video DVD – $5 per DVD
• Electronic Copies @ 25¢ each
• Mailing Lists (Commercial Use) - $1 per name
• Delivery Charges – Actual cost of postage or delivery
# of 8.5x11” Pages Reproduced/Provided:
# of Pages @ $1.00:
=
$
# of Pages @ 50¢:
=
+
$
TOTAL DUE
or
Commercial Use Charges (if different):
$
$
TOTAL DUE
Commercial Use Mailing Lists # of Names @ $1 ea:
$
TOTAL DUE
# of Audio CDs Reproduced @ $5 ea:
# of Video DVDs Reproduced @ $5 ea:
$
TOTAL DUE
Processing Time @ $10.00 per hour:
________________
TOTAL DUE
$
Postal or Other Delivery Charges:
$
$
TOTAL DUE
TOTAL DUE FOR ALL RECORDS PROVIDED
$
Payment Received:
Cash
Check #
Documents Mailed/Faxed/Provided on (Date)
and Receipt Issued by
ADR005 (Revised 10/06/2016)
Public Records Reproduction Request Form/Information and Instruction Sheet
Page 2 of 2
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