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Printed Name Signature Date Mailing Address City State F140-098-000 Request for Confidentiality 10-2016 Zip Code Phone Number RESET. I declare under penalty of perjury of the laws of the state of Washington that the foregoing is true and correct. Request for Confidentiality Return completed form to the inspector or investigator with whom you are working. Program Name Case Number I am requesting that my identity not be disclosed as part of the case file and I am not willing to provide a...

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Return completed form to the designated department or individual.

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