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PDFWAC 446-20-410

Form of request to review refusal to modify record.

request for review of refusal to modify record
 
Date. . . .
I,   (Print Name)   , request the head of    (Agency Name)   , to review and make a final determination of my challenge to the accuracy or completeness of my criminal history record information maintained by     (Agency Name)   .
My challenge, a copy of which is attached, was made on     (Date of Challenge)   , and was refused on    (Date of Refusal)   . I request that my challenge be allowed and my record be modified in accordance with such challenge.
 
. . . .
(Signature of Applicant)
 
. . . .
(Address of Applicant)
 
. . . .
[Statutory Authority: Chapters 10.97 and 43.43 RCW. WSR 10-01-109, § 446-20-410, filed 12/17/09, effective 1/17/10. Statutory Authority: RCW 10.97.080 and 10.97.090. WSR 80-08-057 (Order 80-2), § 446-20-410, filed 7/1/80.]
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