agency. . . .

 

agency case no. . . . .

address. . . .

 

date. . . .

 

. . . .

 

I, (Print Name) , Date of Birth hereby acknowledge receipt this date, . . . . . . . . , of a copy of a Washington State Patrol Criminal Records Division RAPsheet bearing SID number . . . . . . , consisting of . . . . page(s) and identified as a history of criminal offenses charged to me.

I challenge the following specific portion(s) of the CHRI as being inaccurate or incomplete:

 

 

 

. . . .

 

. . . .

 

. . . .

 

. . . .

. . . .

 

. . . .

 

. . . .

 

. . . .

. . . .

 

. . . .

 

. . . .

 

. . . .

and request modification to read:

I further request that the following designated persons or agencies who have received copies of the record be advised of the modifications.

 

 

. . . .

(Signature of Requestor)

Prints of right four fingers taken simultaneously together