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JEFFERSON COUNffCEXVED
DEe 2 3 2005
I Request for Access; to Public Recor~ERSlIN COUNTY OeD
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E jW A,e"eow57lJvJ L Rd
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Name: /<. J;. t-L 7
Street Address: ~ 1- 9 t)
Mailing Address:
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I understand that Washington State law (RCW 42.17.260(9) prohibits the use of lists of individuals for
commercial purposes and I hereby swear and affirm on oath and under penalty of law, that I will not use the
information obtained from this request for commercial purposes and that I will protect and hold harmless,
including the costs of defending, the agency and its agents and employees from which I have obtained said
records, from any and all claims arising either directly or Indir~ from the commercial use of said records.
Signature:
Date:
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. FOR OFFICIAL USE ONLY I
Dept. Sent to:
Date Received:
1__ By: (5.........
days from receipt)
I i
I
I
I
D =est Approved and Fulfilled I valuation Necessary. Estimate days for final response. Notified requester by mail
Request Denied. IMMEDIATELY forward form to Prosecuting Attorney for review
Date Sent:
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D R~ Partially withheld I
Reason Denial and/or Withholding Part of Record:
Comment
Signature:
D D DENIAL Department to notify requester by mail of.reaso. ns for denial,
APPROVAL ~r:.rd copy of request form and writtr e,,~ tyfEMdminiStrator's
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Date:
Signature:
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