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MARYSVILLE POLICE DEPARTMENT Request for Patrol Check Date of Request_____________Departure Date______________Return Type of Premise to be Checked Residence Business of Protected by Alarm System______Lights On______#You can be reached Will anyone be working about or have access to the premises during your absence Yes No they have a they have a Vehicles Left on Vehicles Left on Vehicles Left on Vehicles Left on Any pets Left on Premises______Type____________Who is caring for Addition PLEASE WRITE ANY MORE INFORMATION WE WOULD NEED ON BACK Date Time Condition of Premises Initials Upon receipt of a completed and signed form, members of the Marysville Seniors Against Crime will conduct the check and document their results. House address numbers must be displayed and visible at the location. If the requestor returns to the residence before the return date listed on the form, the requestor is required to notify the Marysville Police Department immediately so the checks can be stopped. THE UNDERESIGNED DOES HEREBY GRANT AND REQUEST THE CITY AND ITS POLICE DEPARTMENT TO VISUALLY CHECK UPON THE PROPERTY LISTED ABOVE. THE UNDERSIGNED DOES HEREBY AGREE TO HOLD HARMLESS THE CITY, ITS EMPLOYEES AND AGENTS FOR ANY AND ALL CLAIMS FOR PERSONAL INJURY, LOSS OR DAMAGE TO PROPERTY THAT MAY BE SUFFERED BY THE UNDERSIGNED THROUGH ANY ACTION OR LACK THEREOF BY A REPRESENTATIVE TO THE CITY. FURTHER, THE UNDERSIGNED UNDERSTANDS AND AGREES THAT THIS IS VOLUNTARY, FREE SERVICE, DOES NOT CREATE A SPECIAL DUTY UPON THE CITY, WILL BE PROVIDED ONLY AS TIME IS AVAILABLE, AND NO GURANTEEIS MADE NOR ASSURANCE GIVEN AGINST LOSS, THEFT OR DAMAGE TO PREMISES. Signed day Marysville Crime Prevention 1635 Grove St, Marysville, WA 98270 Marysville Police Department [PHONE REDACTED] [EMAIL REDACTED] [PHONE REDACTED] Revised 11/18/08