Public Records Request

Department of Financial Institutions PUBLIC RECORDS REQUEST PO Box 41200 Olympia, WA 98504-1200 (360) 902-8804/FAX: (360) 704-6955 cspublicrecords@dfi.wa.gov CONTACT INFORMATION Name Company Mailing Address City, State, ZIP Daytime Telephone Number (8-5, PST) Email ( ) Date Stamp (receipt) REQUESTED RECORDS Financial Institution or File No. (if applicable): Subject of request: Division (if known) Date Range (if available): Please describe the records you are requesting below. Optional: You are not required to provide any information about the purpose of your request. However, providing information about the purpose of your request may allow DFI to identify additional records and provide faster service. CONDITIONS FOR RELEASE OF PUBLIC RECORDS RCW 42.56.070(9) prevents DFI from providing a list of individuals to anyone for use in any commercial activities. If your request includes a list of individuals, you may be required to sign an affidavit of non-commercial purpose. Yes No Where DFI maintains multiple identical copies of a record, do you want a single copy of each record? This will decrease the time to fill your request. T e Signature of Person Requesting Public Document Date Pursuant to RCW 42.56.070(7)(e), agencies may seek reimbursement for costs directly incident to the request DO NOT SEND ANY MONEY UNLESS YOU ARE NOTIFIED OF COSTS Signature Authorizing Release of Records Date American LegalNet, Inc. www.FormsWorkFlow.com