To
whom will the data be disseminated?:
If this information concerns a names individual, please give the necessary identifying
information.
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.
FOR COURT USE ONLY
Information Disseminated By: _____________________________________________________
Date Information Disseminated: ___________________________________________________
click to sign
signature
click to edit
![]()
