MH - Public Access Option Form COFFELL PUBLIC ACCESS OPTION FORM
Texas Government Code Section 552.1 17(a)(17)
The Public Information Act allows applications and forms submitted by current or
former public officials to contain redactions of information including home
address and home phone number pursuant to Section 552.1 17(a)(17) of the Texas
Government Code, as amended by House Bill 1082 (87th regular Legislative
Session). Unless you choose to keep it confidential, the following information
about you may be subject to public release if requested under the Texas Public
Information Act. Therefore, please indicate whether you wish to allow public
release of the following information.
Printed Name
Do you Give Permission for Public Access to: NO YES
Please indicate by placing an "X" in appropriate box.
Home Address
Home Phone Number
Cell Phone Number
Email Address
Social Security Number
Information that reveals whether you have family members.
Emergency Contact Information X
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Signature Date