When complete, return form to:
Public Records Officer
Jefferson County Library District
620 Cedar Ave.
Port Hadlock, WA 98339
Or email to: publicrecords@jclibrary.info
Name of Requestor: ___________________________________________________________________
Address: _____________________________________________________________________________
City: _____________________State: _______ Zip: _________ Phone: ___________________________
Email Address: ________________________________________________________________________
Pursuant to Washington State Law, RCW 42.56, I request inspection of the following records:
Title of Record(s) (if known): ____________________________________________________________
Date of Record(s) (if known): ____________________________________________________________
Please describe below the records you are requesting and any additional information that will help us locate them for you as quickly as possible._________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
The District will respond within five (5) business days acknowledging that your request has been received.
I understand that there may be charges for duplication of these requested records. (See attached Fee Schedule for more information)
I wish to receive copies/duplicates of the records indicated above. ____Yes _____No
If the requested records are exempt from public disclosure, I understand that the Public Records Officer will provide the specific reason for the exemption.
Signature:____________________________________________Date:________________________________
RCW 42.56 prohibits the use of lists of individuals for commercial purposes. If you are requesting a list of individuals, please also complete the Commercial Purpose Declaration Form.
PUBLIC RECORDS – COPY FEE SCHEDULE
For reasons stated in Resolution No. 24-10, adopted by the Boad of Trustees on 08/14/2024, and incorporated herein by reference, the District finds that it would be unduly burdensome and would interfere with District operations to calculate all actual costs for providing records. Instead, fees for paper or electronic copies will be charged pursuant to the state statutory default copying charges detailed in RCW 42.56.120:
- 15 cents/page for photocopies or printed copies of electronic records;
- 10 cents/page for records scanned into electronic format;
- 5 cents for every four electronic files or attachments uploaded to an email, cloud storage service, or other electronic delivery system;
- 10 cents/gigabyte for transmitting records electronically;
- The actual cost of the digital storage media/device, container used to mail the copies, and postage or delivery charges;
- A customized service charge for requests that would require information technology expertise to prepare data or provide customized electronic access.
At their discretion, the Public Records Officer may elect to waive these fees. Fees may generally be waived when the expense of billing exceeds the cost of copying and postage.
COMMERCIAL PURPOSE DECLARATION
PUBLIC RECORDS REQUESTS UNDER RCW 42.56 FOR LISTS OF INDIVIDUALS
You, your organization, or business has requested a list of individuals from a public agency.
The Washington State Public Records Act (PRA) at RCW 42.56.070(8) directs that:
This chapter shall not be construed as giving authority to any agency, the office of the secretary of the senate, or the office of the chief clerk of the house of representatives to give, sell, or provide access to lists of individuals requested for commercial purposes, and agencies, the office of the secretary of the senate, and the office of the chief law clerk of the house of representatives shall not do so unless specifically authorized or directed by law: PROVIDED, HOWEVER, that lists of applicants for professional licenses and of professional licensees shall be made available to those professional associations or educational organizations recognized by their professional licensing or examination board, upon payment of a reasonable charge therefor: PROVIDED FURTHER, that such recognition may be refused only for a good cause pursuant to a hearing under the provisions of RCW 34.05, the Administrative Procedure Act.
The PRA at RCW 42.56.080 authorizes agencies to require a requester to provide information as to the purpose of a request “to establish whether inspection and copying would violate RCW 42.56.070(8).”
INSTRUCTIONS:
In order to ensure compliance with this obligation please complete the declaration on the reverse of this form and return it to the Public Records Officer. If our agency does not receive a completed declaration, we will be unable to process your request for the list and the request for the list will be administratively closed. If we have questions for you after you complete the declaration, we will contact you. Therefore, make sure you also provide contact information at the bottom of the declaration.
Return this completed declaration form (both sides) via mail or email to the Public Records Officer at:
Jefferson County Library District
Attention: Dr. Tamara Rotz, Director/Public Records Officer
620 Cedar Ave.
Port Hadlock, WA 98339
This declaration is a public record.
DECLARATION UNDER PENALTY OF PERJURY
1) I have requested a list of individuals from the Jefferson County Library District.
2) I am requesting the list of individuals on behalf of (choose one):
______ My Personal Behalf (skip to 3)
______ Organization or Business (complete a.-c. before 3)
a. If an organization or business, the name of the organization or business is: _________________________________________
b. If an organization or business, the purpose of the organization or business is: _________________________________________
c. If an organization or business, the mailing address and website address are: _________________________________________
- The purpose of making this request for the list of individuals is:__________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
- I or the organization/business intend to generate revenue or financial benefit from using the list of individuals: ____Yes ____ No
- I or the organization/business intend to solicit money or financial support from any of the individuals on the list: ____Yes ____ No
- I or the organization/business intend to make individuals on the list aware of business commercial entities: ____ Yes ____ No
- I or the organization/business intend to supply or sell the list of individuals to an organization or business, third party individual (someone other than myself or the organization or business listed in Paragraph 2), or any other entity: ____ Yes ____ No
If yes, to whom: ___________________________________________________________
- I or my organization/business attest that another law authorizes or directs the agency to provide me or my organization/business the list of individuals requested: ____ Yes ____ No
If yes, provide specific citation: _____________________________________________
I certify under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. I certify under penalty of perjury that I have read this declaration form and I understand that a list of individuals cannot be provided to me or to my organization or business by a public agency if the list will be used for a commercial purpose. I certify under penalty of perjury that any list of individuals I or my organization or business receive pursuant to the request dated ___________ to the Jefferson County Library District will not be used for any commercial purpose in violation of RCW 42.56.070(8).
DATED this _____ of_______________, _____ in ___________________________.
___________________________________________
Signature of Declarant
__________________________________________
Printed Name
___________________________________________
Title (if any)
__________________________________________
Contact Information (phone and/or email)