1998, 09-15 Req for Disclosure of Recordsft
DEIl1L&HEAURTT4EN OHF
SOCJA
SERVICES
REQUEST FOR DISCLOSURE OF RECORDS
OAJ OF I EQUEST
TIME OF REQUEST .
NAME OF REQL•}EST�
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DESCRIPTION OF REC EST OR INFORMATION REQUED: r - \ 1/1 (i ( pn ► lie` bi 1
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OF \ C1r1:1 REQUEST IS MADE
EMPLOYEE RECEIVING REQUEST
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IF PERSONAL INFORMATION OR RECORD IS REQUESTED, GIVE NAME OF PERSON OR PERSONS REGARDING WHOM INFORMATION
IS REQUESTED.
NAME
IF THE ABOVE NAMED IS A MEMBER OF A HOUSEHOLD, GIVE NAME OF HEAD OF HOUSEHOLD:
NAME OF HEAD OF HOUSEHOLD
ADDRESS OF PERSON NAMED WHEN RECORD WAS LAST UTILIZED:
STREET ADDRESS CITY STATE ZIP CODE
WHAT IS YOUR RELATIONSHIP TO PERSON NAMED -
I WISH TO INSPECT THE REQUESTED INFORMATION AT THE DEPARTMENT OF SOCIAL AND HEALTH SERVICES OFFICE AT
NAME OF LOCATION
I WISH A COPY OF THE INFORMATION OR RECORD REQUESTED AND I UNDERSTAND THAT A FEE MUST BE PAID PURSUANT TO
WAC 388-320-140.
I UNDERSTAND THAT I MAY BE REQUIRED TO PROVIDE POSITIVE IDENTIFICATION FOR DISCLOSURE OF PERSONAL INFORMATION.
FURTHER, I UNDERSTAND THAT I MAY BE REQUIRED TO OBTAIN A SIGNED RELEASE FROM THE PERSON CONCERNED IF THE
INFORMATION IS CONTAINED IN RECORDS OTHER THAN MY OWN.
I FURTHER CERTIFY THAT ANY INFORMATION DISCLOSED, WILL NOT BE USED FOR,COMMERCIAL PURPOSES.
DATE INFORMATION OR COPIES REQUIRED. 9 I
15 G
DATE REQUEST RECEIVED:
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SIGNATURE OF REQUESTOR
DSHS 17-041 (X) (REV. 9/82)