Pierce County by ls723a4r


									                                                       Pierce County
                                            Request for Access to Public Records
Requests and production are governed by Chapter 42.56 RCW and Chapter 2.04 Pierce County Code (PCC)

Instructions: 1. Complete Section A of the following form. Please Print.
              2. Mail, deliver, or fax completed form to the Public Records Officer for the Pierce County Department/Office you are
requesting records from.

SECTION A           Requester / Records Request Information - Please PRINT
Requester Name                                                 Business Name

Address                                                             City                                             State - Zip Code

Phone Number                                                        Fax Number

Complete only one box below:
   Do not make copies, but allow review. P.C. Code Chapter 2.04. I may request copies of specific pages after review.
   mail copies*        hold copies for pickup* (prior payment is required for copies mailed or picked up).
*I understand that I will be charged 15 cents per page or the published cost of copies requested, whichever is greater, plus mailing cost, if
mailing is requested. P.C. Code Chapter 2.04

Please describe the SPECIFIC record(s) you are requesting, including dates(s):

____________________________________________                                       _______________________
Signature of Requester                                                             Date Submitted

SECTION B        The following must be signed ONLY if you request any list of individuals.
I declare under penalty of perjury under the laws of Washington that the following is true and correct: I will not use any requested list of
individuals for a commercial purpose (profit expecting activity).

Signed this ____ day of _____________, 201__ at__________________(city),_______(state). RCW 42.56.070(9) and PCC 2.04.030(D)(5)

Requester’s Signature: ____________________________________

PRR Form Rev. 10/25/2011

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