You may contact the department to physically sign and send in a certificate. Certification I , as the requestor of the records described in (required) the letter, form or email sent previously the section below (“Description of Records Requested”) Date Letter, form or email was sent previously hereby state that consistent with KSA 45-230 I do not intend to, and will not (A) use any list of names or addresses contained in or derived from the records or information for the purpose of selling or offering for sale any property or service to any person listed or to any person who resides at any address listed; or (B) sell, give or otherwise make available to any person any list of names or addresses contained in or derived from the records or information for the purpose of allowing that person to sell or offer for sale any property or service to any person listed or to any person who resides at any address listed. I declare or certify under penalty of perjury under the laws of the State of Kansas that the foregoing is true and correct. I declare or certify under penalty of perjury under the laws of the State of Kansas that the foregoing is true and correct. Signature of Requestor To sign, please type your first and last name. Contact Information Name (required) Mailing Address (required) City (required) State (required) AA AE AP Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming ZIP Code (required) Phone Number Email Address Request Details Description of Records Requested (required)