City of North Bend
Public Records Request Form
920 SE Cedar Falls Way - P.O. Box 896
North Bend, WA 98045
Phone 425-888-1211
Fax 425-831-6200
Note: The City of North Bend will attempt to meet your request as soon as possible within time and availability
constraints. If the record(s) is not readily available you will be notified within five (5) working days as to when
the record(s) will be available. There may be a charge for the record(s) you are requesting.
Section 1 - To Be Completed by Requestor
Your name: Phone:
Mailing address:
Describe the record(s) you are requesting. Please supply as much identifying information as possible to
assist staff in locating the records quickly. Examples: specific date ranges, document titles, names, addresses,
parcel numbers. Use back of form if necessary.
How do you want the record(s) made available? Review at City facility:
If available e-mail to: ______________________________ Copy provided:
I understand Washington State law restricts certain uses of public records, including but not limited to RCW
42.56.070(9) prohibiting using lists of individuals for commercial purposes. I hereby declare under penalty of
perjury and the laws of the State of Washington that the requested records shall not be used in violation of State law.
Signature: ____________________________________________ Date:
Section 2 - For Internal Use Only
Employee receiving request: Date received:
Original forwarded to: and a copy sent to City Clerk
Date received by Dept: Initial action taken:
By: Date:
Final action:
By: Date:
After final action send original request and all documentation to the City Clerk.
Amount due:
Date paid:
Receipt #:
Received by:
Staff Member
Section 1 Continued - To Be Completed by Requestor
Section 2 Continued - For Internal Use Only