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EVERETT POLICE DEPARTMENT STATEMENT FORM <br /> CASE# DD I ti9 <br /> STATEMENT OF: gt,_"d 11 C 111 : <br /> LanNAME RRSr NAME MIDDLE NAME <br /> 1,0 ISA 1 q9'")7-Slo `pec � Z 3 0 ,(���j <br /> RACE SEX DATE OF BIRTH WEIGHT EYE COLOR HAIR COLOR <br /> RESIDENCE: Z-i I QO f' K/ b ?_19,__ ell- .240t /` W <br /> STATE DTP <br /> HOME PHONE#: WORK/CELL#: EMPLOYMENT: <br /> ALTERNATE CONTACT(IN CASE OF RELOCATION): <br /> 6 01‘,. ..5"-:"Z--1, -La "r_ 1-d--i-- <br /> kot44.)-L. +0 e <br /> ' '„ k. P'k r r zr v'vi� f ( v, PK v � <br /> ,e,.� -5'�t.- ©>+* O I+t. >c em,r zJ� r----=A0/9/4 s ia IT/L.& <br /> r ke. - YLdV �- a I �� e k .I I <br /> k 6CI1 tVk . <br /> ',jib+” l inn 14-e--13 US IA• - CD t9� i)rA.�-- gvia <br /> JO ZU'ILZ <br /> tyt <br /> A - , f ( A t Ilii lI 1 A' .4 / r itt LS <br /> M <br /> A - . 21 & n GABS illiS, <br /> 1tA 6904 .i kr4 S ,l5 .�.i ► ,' <br /> , 0, - t)- ' ____ak " 40 i} J 1, - <br /> .0 Y\ t A tiw o1 ► • ik.iSvi/t eSAT i 1 1 <br /> J .c._--e..- do. .to 1 k IV Ag . Apr ,..., 4- ,A. dit, S ' 'Ali\ <br /> , ► h/ - AJ sit _i Ai T• ' .ug 1 4'1) ± I <br /> THIS STATEMENT WAS WRITTEN ON MY BEHALF BY: <br /> I DECLARE UNDER THE PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE <br /> FOREGOING WRITTEN STATEMENT, CONSISTING OF t PAGES, IS TRUTHFUL AND ACCURATE TO THE <br /> BEST OF MY PSONAL KNOWLEDGE. EACH PAGE AND ALL CORRECTIONS, IF ANY, BEAR MY INITIALS_ <br /> I HAVE READ [ HAVE BEEN READ j ] THE FOREM DECLARATION AND UNDERSTAND THAT THIS <br /> DOCUME MA BE USED IN A COURT OF LA <br /> LA.9 <br /> r"-----' PECLARANT SIGNATURE) (OFFICER OR WITNESS SIGNATURE) <br /> t)e'et cdi4- <br /> (CITYI AND STAT IAMERE SIGNED) (DATE OF STATEMENT) 12._Page 'L of (INIT.) <br /> PD-004 Rev.7/2007 <br />