Form LTC-85 Authorization for Release of Records Affidavit - Texas

Form LTC-85 is a Texas Department of Public Safety form also known as the "Authorization For Release Of Records Affidavit". The latest edition of the form was released in July 1, 2017 and is available for digital filing.

Download a PDF version of the Form LTC-85 down below or find it on Texas Department of Public Safety Forms website.

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AUTHORIZATION FOR RELEASE OF RECORDS AFFIDAVIT
STATE OF
§
§
(STATE whErE nOTArizEd)
§
COUnTY OF
§
(COUnTY whErE nOTArizEd)
BEFOrE ME, the undersigned authority, personally appeared
, who
made this Affidavit and, on oath, stated the following:
(PrinTEd nAME OF APPLiCAnT)
“I hereby authorize the release of information and records pursuant to Section 411.174(a)(9) of the Texas Government
Code, to the Texas Department of Public Safety for the purpose of a background investigation to determine my eligibility for
a license to carry a handgun or to instruct applicants for such licenses.”
“Such records may include, but are not limited to:
1. All records, reports and testimony relating to the medical condition of an applicant or license holder for use as
allowed pursuant to Section 12.097, Texas health and Safety Code;
2. Child support payment status as evidenced by court documents or records from the Office of the Attorney
General;
3. Payment status of taxes or other money collected by the Comptroller, State Treasurer, tax collector of a political
subdivision of the state, Texas Alcoholic Beverage Commission, or any other agency or subdivision of the state,
as evidenced by tax or agency records;
4. Files and records of the juvenile court relating to applicant pursuant to Section 58.003(m), Texas Family Code;
5. Law enforcement records, including offense or arrest reports;
6. Current restrictions under a court protective order;
7. Court documents reflecting pending charges or final dispositions.”
Applicant’s Signature
SUBSCriBEd and SwOrn TO before me on this
day of
, 20
.
(dAY)
(MOnTh)
(YEAr)
nOTArY PUBLiC Signature
[seal]
Printed name of nOTArY PUBLiC (if not on seal)
LTC-85 (Rev. 7/17)
AUTHORIZATION FOR RELEASE OF RECORDS AFFIDAVIT
STATE OF
§
§
(STATE whErE nOTArizEd)
§
COUnTY OF
§
(COUnTY whErE nOTArizEd)
BEFOrE ME, the undersigned authority, personally appeared
, who
made this Affidavit and, on oath, stated the following:
(PrinTEd nAME OF APPLiCAnT)
“I hereby authorize the release of information and records pursuant to Section 411.174(a)(9) of the Texas Government
Code, to the Texas Department of Public Safety for the purpose of a background investigation to determine my eligibility for
a license to carry a handgun or to instruct applicants for such licenses.”
“Such records may include, but are not limited to:
1. All records, reports and testimony relating to the medical condition of an applicant or license holder for use as
allowed pursuant to Section 12.097, Texas health and Safety Code;
2. Child support payment status as evidenced by court documents or records from the Office of the Attorney
General;
3. Payment status of taxes or other money collected by the Comptroller, State Treasurer, tax collector of a political
subdivision of the state, Texas Alcoholic Beverage Commission, or any other agency or subdivision of the state,
as evidenced by tax or agency records;
4. Files and records of the juvenile court relating to applicant pursuant to Section 58.003(m), Texas Family Code;
5. Law enforcement records, including offense or arrest reports;
6. Current restrictions under a court protective order;
7. Court documents reflecting pending charges or final dispositions.”
Applicant’s Signature
SUBSCriBEd and SwOrn TO before me on this
day of
, 20
.
(dAY)
(MOnTh)
(YEAr)
nOTArY PUBLiC Signature
[seal]
Printed name of nOTArY PUBLiC (if not on seal)
LTC-85 (Rev. 7/17)

Download Form LTC-85 Authorization for Release of Records Affidavit - Texas

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