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CODE VIOLATION REPORTING FORM Code Enforcement Unit 1635 Grove Street, Marysville, WA 98270 FOR AGENCY USE Date: Case Number: VIOLATION INFORMATION Describe the violation, and provide any relevant comments OWNER OF PROPERTY WHERE VIOLATION IS OCCURRING PERSON REPORTING VIOLATION WITNESS (if any) Name Address City, State, ZIP Phone (home/office) Phone (cell) E-mail CONFIDENTIALITY Under Chapter 42.56 RCW, the Public Records Act, a Complaint Form is a public record subject to disclosure. You, as a complainant, may request that your identity not be disclosed to the public. If you request that the City not disclose your identity, the City will attempt to honor your preference, but makes no assurances that your identity will not be made public. Additionally, if the complaint results in a case being filed in court, you will most likely be named as a witness and your identity will therefore be disclosed. Please check one I request that the City attempt to keep my identifying information confidential Upon a public records request, my identifying information may be disclosed CERTIFICATION I certify (or declare) under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct (RCW 9A.72.085). Signature (required) Date