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2. Pursuant to IC 36-1-8.5, HEA 1371, the following covered persons must submit a written request to the Hamilton County Auditor to restrict access through a public property data base web site to his/her home address as it appears in the county’s tax management system:

4. 1. A Judge -

   a) supreme court, court of appeals, tax court, circuit court, superior court, municipal court, county court, federal court, small claims court, probate court, city court, town court; or 

   b) magistrate, commissioner, juvenile referee of a court, pro tempore, senior judge, temporary judge or any other individual including retired judicial officer serving as a judge.

6. 2. A law enforcement officer ‐
   1. A police officer (including a correctional police officer), sheriff, constable, marshal, prosecuting attorney, special prosecuting attorney, special deputy prosecuting attorney, the securities commissioner, or the inspector general; or,
   2. A deputy of any of the persons specific in subdivision (a); or,
   3. An investigator for a prosecuting attorney or for the inspector general; or,
   4. A conservation officer; or,
   5. An enforcement officer of the alcohol and tobacco commission; or,
   6. An enforcement officer of the securities division of the office of the secretary of state.
8. 3. A victim of domestic violence –
   1. Who is certified as a program participant in the address confidentiality program established by the attorney general under IC 5-26.5-2.
10. 4. A public official ‐
    1. An individual who holds or formerly held office at any time during the preceding four (4) years in the executive or legislative branch of the state or federal government or a political subdivision of the state or federal government
12. 5. Surviving spouse of person described in sec 2 if the person was killed in the line of duty.
14. 6. Employee of the Department of Child Services.
16. 7. Current or former probation officer
18. 8. Current or former community corrections officer
20. Please Check one box:*

    1. Judge
    2. Law Enforcement/Probation/Community Corrections (current or former)
    3. Victim of Domestic Violence
    4. Public Official
    5. Department of Child Services
    6. Surviving Spouse
22. *Disclaimer

    If a property transaction transferring the property to another party occurs, the restriction on said property will be removed.  If the covered person purchases another property, a new form shall be submitted to the County Auditor.)

24. I,
27. First Name*
28. Last Name*

30. request that the Hamilton County Auditor restrict access to the address of my actual personal residence through any record made available to the general public within a public property data base web site that includes my residential information.

32. EMPLOYER INFORMATION

    To verify employment or commission status, please provide employer information. If a Victim of Domestic Violence or a Surviving Spouse, please enter "N/A" in these fields.

34. Employer Name:*
35. Contact Information*
37. Employer Address
39. Street Number*
40. Street Name*
41. Street Type*
42. Apt #
44. City*
45. State*
46. Zip Code*
48. 
    
    
50. REQUESTER'S INFORMATION
52. Requester's Address
54. Street Number*
55. Street Name*
56. Street Type*
57. Apt #
59. City*
60. State*
61. Zip Code*
63. Requester's Area Code and Phone Number*
64. Requester's Email Address*
66. Requester's Signature*

    l hereby certify that the above statement is true, correct and complete.

67. 
    
    
Leave This Blank:


69. 1. Receive an email copy of this form.
70. Email address

    This field is not part of the form submission.

71. Submit

* indicates a required field