Section 1 of 1 in this document
Statement Form
Case Number
*
Date
Citizen Statement
*
I certify under oath and penalty of perjury under the laws of the State of Washington that the above statement is true and correct. I further certify that the statement is made by me freely, voluntarily and without threat or promise of any kind.
I agree.
Full Name
First Name
*
Initial
Last Name
*
Date of Birth
Email
*
Full Address
Street Address
*
City
*
State
*
Zip
*
Phone Number
*
I am requesting nondisclosure of my personal identifying information (name, address and phone numbers) pursuant to RCW 42.56.240(2). I believe disclosure of my personal identifying information would endanger my life, physical safety, or property. I understand that this only pertains to the case number listed above.
Yes
No
Signature
Signature
First Name
Last Name
Email
Choose how to sign
Draw
Type
I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.
disregard this