Department of Judicial Administration Barbara Miner Director and Superior Court Clerk (206) 296-9300 (206) 296-0100 TTY/TDD Page 1 of 2 REQUEST FOR INFORMATION / DATA DISSEMINATION Please complete and return this form to: Department of Judicial Administration Attn: Arnold Bahr 516 Third Avenue Seattle, WA 98104-2386 or Email: Arnold.Bahr@kingcounty.gov **Do not send payment with this form. You will be invoiced at a later date.** The information you provide below is necessary to process your request for data from the Judicial Information System. Your request is subject to approval under the provisions of JISCR 15 and the Judicial Information System Data Dissemination Policy and the local Data Dissemination Policy and Procedures. Upon approval, the request will be forwarded to a programmer who will examine it and contact you to work out any necessary details. There is a charge for such reports as governed by JISC policy. If you have questions about this form, please contact the Data Dissemination Coordinator at (206) 477-3033. Name: Agency or Company: E-mail Address: City: State: Zip: Day or Work Phone: (with area code) Fax Number: (with area code) Information Requested (provide as much detail as possible and attach additional pages if necessary): What will the information be used for? To whom will the data be disseminated? American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 Effective 8/1/2018 If this information concerns a named individual, please give necessary identifying information (i.e. date of birth, driver222s license number, most current address, etc.): Date information is needed: Medium Requested: CD Paper E - mail Attachment The following fees are applied to information requests that require generation of a report from JIS. Fees do not include printed copies of electronic documents such as dockets or screen prints. Administrative Costs Data Warehouse Evaluation/Research/Programming: $55.00/Hour Data Reporting Evaluation/Research: $54.00/Hour CPU Minutes: $12.00/Minute Administrative Fee: $50.00/report Material Costs Hardcopy: $1.00/Page Electronic File: No Charge I, the undersigned: Agree to use and distribute the information only as provided in the above referenced statement of intended use; Agree not to use the data received under this request for the commercial solicitation of individuals named in the records (Data Dissemination Policy III.C; GR31(g)(3)); Agree to pay, unless payment is waived, the cost quoted or invoiced by the Department of Judicial Administration; Understand that the Department of Judicial Administration make no representation as to the accuracy or completeness of the data; Agree to indemnify and hold harmless the Department of Judicial Administration from any claims or damages arising from the use and distribution of the information responsive to this request; and Certify, under penalty of law, that all the information supplied above is true and a complete description. Signature of Requestor: Date: American LegalNet, Inc. www.FormsWorkFlow.com