State Of Washington
Upper Kittitas County District Court
Request for Information
The following information is necessary for us to process your request for data from the Judicial
Information System (JIS). Please complete this form and return it to:
Upper Kittitas County District Court
Judge Darrel R. Ellis
700 East First Street
Cle Elum, WA 98922
Fax: (509) 674-4209
Your request is subject to approval under the provisions of JISCR 15, the JIS Data Dissemination
Policy, and the local Data Dissemination Policy and Procedures. Upon approval, the request will
be reviewed. There is a charge for such reports as governed by JIS Committee Policy.
Name: (Please print) ____________________________________________________________
Agency of Company: ____________________________________________________________
Address: _________________________________________ email: ______________________
City: __________________________________ State: ______________ Zip: ____________
Day or Work Phone: (_____)_____________________ Fax No: (_____)___________________
Information Requested (provide as much detail as possible)
What will the information be used for?
whom will the data be disseminated?:
If this information concerns a names individual, please give the necessary identifying
Full Name: ____________________________________________________________________
Date of Birth: __________________________________________________________________
Driver’s License Number: ________________________________________________________
Most Current Address: ___________________________________________________________
Date Information Needed: ________________________________________________________
I, the undersigned:
Agree to use and distribute the information only as provided in the above reference
statement of intended use;
Agree not to use for commercial purposes (Data Dissemination Policy IIIA(5);
Agree to take reasonable precautions to prevent disclosure of information beyond
the above referenced statement of intended use;
Agree to pay, unless payment is waived, the cost upon fulfillment of the request and
receipt of invoice from the Upper Kittitas County District Court;
Understand that Kittitas County makes no representation as to the accuracy and
completeness of the data except for court purposes and agree to indemnify and hold
harmless the Upper Kittitas County District Court from any claims for damages
arising from applicant’s use and distribution of the information; and
Certify, under penalty of law, that all the information supplied above is true and a
complete description.
________________________________________ ______________________________
Signature of Requestor Date
Please attach additional pages for more detailed responses or comments.
Information Disseminated By: _____________________________________________________
Date Information Disseminated: ___________________________________________________
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