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/Jo 367/Zt{U07 (/UhtitAf Jt/5n&? , declare under penalty of
perjury that, according to my belief, the facts stated in the above application are true and correct.
Signed on '3 Te b 20^.
Signature of Applicant / Petitioner (circle one)
17
Rev. 01/14/14
h.
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INMATE REQUEST FOR INFORMATION
SID#
UNIT: MAIN JAIL:
CIRCLE ONE (1) SECTION ONLY OR REQUEST WILL BE VOIDED
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Information
Provided By:
Section:
Inmate's Signature (Sign At Time Of Request)
BCSOFORM351-171 REVFEB '13