Seattle Police Department
Clearance Letter Request
Form 21.6 Rev 7/11
PLEASE PRINT LEGIBLY
Name of Requestor: (Person filling out form)
Name of person requiring a clearance letter: (If different from requestor)
Mailing Address (address/city/state/zip)
The clearance letter will be sent to this address
Phone #
Other names legally used: (maiden name, legal name change, etc)
Birth Date
X
I want the letter mailed
I will pick up the letter on
the next business day after
2:00.
Requestors Signature
Today’s Date
Instructions
Complete the form with all required information and present the form in person at SPD Public Request Unit located at 610-5
th
Ave.,
Seattle, 98104. Payment of $22.50 (notarized) or $17.50 (non-notarized) must be made in the form of cash, check or money order.
You may also mail the completed form along with a photocopy of identification and the aforementioned payment to:
Seattle Police Department-PRU, P.O. Box 34986, Seattle WA. 98124-4986.
Questions? Call 206-684-5454
Official Use Only-Do Not Write Below This Line
Request Received: Counter Mail Received by: (Ser#)
ID Verified: Disclosed by: (Ser#) Date:
Letter mailed through USPS:
Letter placed in will call:
