[City Of Prosser] PD Statement Form

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.

Date of Birth

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

Signature

First Name

Last Name

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.