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BW9-3

7/2011

REQUEST FOR PEACE OFFICER CONFIDENTIALITY

FOR SECRETARY OF STATE OR LOCAL VOTER REGISTRATION OFFICE

Pursuant to Section 552.1175 of the Government Code, if you are a peace officer, county jailer, current or former employee

of the Texas Department of Criminal Justice, or a commissioned security officer, you may request that information in the

voter registration records identifying your home address, home telephone number, social security number, or whether you

have relatives be restricted from public access. By completing and submitting this form to the County Voter Registrar’s

Office, you are requesting the confidentiality of the voter registration information as stated above. You must attach a

photocopy of documentation showing that you are eligible for confidentiality. If you want to rescind this confidentiality

request, you must do so in writing to the County Voter Registrar’s Office.

Name

Date of Birth

Step 1:

Identify Person

Residence Address (number and street)

Requesting

Confidentiality

City, State, Zip Code

VUID Number

County of Residence

Peace Officer (as defined by Article 2.12, Code of Criminal Procedure

Step 2:

);

Qualification

County Jailer (as defined by Section 1701.001, Occupations Code

(check one)

);

Current or former employee of the Texas Department of Criminal Justice (or

of the predecessor in function of the department or any division of the

department);

Commissioned Security Officer (as defined by Section 1702.002,

Occupations Code);

Employee of a District Attorney (DA), Criminal DA, or Municipal Attorney

whose jurisdiction includes any criminal law or child protective services

matters;

Officer/Employee of a community supervision and corrections department

established under Chapter 76 who perform a duty described by Section

76.004(b);

Criminal investigators of the United States as described by Article 2.122(a),

Code of Criminal Procedure; and

Police officers and inspectors of the United States Federal Protective

Service.

I have attached a photocopy of documentation showing evidence of my

Step 3:

qualification (proof of the qualification claimed above on Step 2).

Evidence of

Status

I certify that the information in this document and any information attached are true and

Step 4:

correct to the best of my knowledge and belief.

Sign and Date

Sign

Here► ___________________________________ Date ►___________________

Return this form to:

County Voter Registrar

Step 5:

____________________________________

Return this form

____________________________________

Or fax to _____________________________

For Office

Certificate # __________________

Documentation received?

Yes

Use Only

Confidentiality Approved?

Yes

Voter Reg. Dept. Signature ________________________________________ Date_________________

Comments: __________________________________________________________________________

If you make a false statement on this form, you could be found guilty of a Class A misdemeanor or a state jail felony under

Texas Penal Code Section 37.10.

By filing this document with the Secretary of State or the local voter registration office, information in the voter registration

records that identifies your home address, home telephone number, social security number, or whether you have relatives

will be restricted from public access until you rescind the request in writing. However, pursuant to Attorney General Open

Records Decision No. 678, the information will be available for the official use of the local voter registration, the state, and

political subdivisions of the state.

Form Bw9-3 - Request For Peace Officer Confidentiality For Secretary Of State Or Local Voter Registration Office

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