Public Service Request - Voter Registration Data (Historic)
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Public Service Request - Voter Registration Data (Historic)
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PSR
Request for Voter Registration Data
Name (Print): ________________________________________________________________________
Address: ____________________________________________________________________________
City, State & Zip: _____________________________________________________________________
Telephone Number: __________________________________________________________________
Email Address: _______________________________________________________________________
Please include detailed description of your request for voter registration data and what it is to be
used for:
_____________________________________________________________________________________
_____________________________________________________________________________________
Time Total Amt.
Format Cost Spent Research Fee Due
Average hourly pay
Copies Letter/Legal = $.10/pg. x # of pages = ________ + ________ x for clerical staff = ________ = ________
CD or other
media Cost of media = ______ x quantity = ________ + ________ x Labor = ________ = ________
Voter
Address Actual cost of
Labels Cost of sheet = _______ x quantity = ________ + ________ x research time = ________ = ________
NOTICE OF APPROPRIATE USE
**MUST READ & SIGN BEFORE REQUEST IS VALID**
Section 115.158 RSMo prohibits commercial use of Centralized Voter Registration System Information.
The statute states: “…Any information contained in any state or local voter registration system, limited to
the master voter registration list or any other list generated from the information, subject to chapter 610,
RSMo, shall not be used for commercial purposes; provided, however, that the information may be used for
elections, for candidates, or for ballot measures, furnished at a reasonable fee. Violation of this section shall
be a class B misdemeanor.” "Commercial purposes" 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.
By your signature below, you represent that you will not use, nor will you knowingly or negligently
permit others to use this information for commercial purposes.
_____________________________________ _______________________________
Signature Date
Request taken by: ______________________________________________________ Deputy Clerk.
Date Paid:___________ Amount Pd.: _______How Pd.: Check/Cash _________ Recvd. By: ___________
Revised by: C Smith on 12/7/2011
Public Service Request - Voter Registration Data (Historic)
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