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8 <br /> EVERETT POLICE DEPARTMENT STATEMENT FORM <br /> CASE# DD t3 - 2 o&i <br /> el) 1t /fit<<� 7"STATEMENT OF: LAST NAME FIRST NAME MIDDLE NAME <br /> I.-7 IM 10-17sre lv/ s-- E/.'„ t3,ey.J <br /> RACE SEX DATE OF BIRTH HEIL,Fri WEIGHT EYE COLOR HAIR COLOR <br /> a-1 S t telt st- 5cA) 4t/540,- <br /> be-if - <br /> RESIDENCE: STREET ADDRESS CITY STATE ZIP <br /> qtA.-- 3`f4' -4/5-5---- <br /> HOME <br /> 4)5 —HOME PHONE#: WORK/CELL#: EMPLOYMENT: <br /> ALTERNATE CONTACT(IN CASE OF RELOCATION): <br /> 5lL ID-/t"-13 ►4f pox 4 6i tAirk.s DO•Ec10cs4 ilpi <br /> v+�t( A'Cik& V1 IAA +0 I lek at c K k u9 r IL <br /> r - SA-4- It 14:1-s 1—Vt'c `. - INC t.i Gcy'it0 eiL alta <br /> 14PAKI- -, f 65 L vbke, kv - c_bo - i-ke4Ak Dt& tee. <br /> IVB �-�( rile e, W A-1 V - ( 9 t-t t,c,a1 V- r Li c c9 t _A,w& lei <br /> (e AIN oyilyiti p t,t t IAS b tt*� <br /> t. �� rite, to r a vt_ ,ct�a,-Ai aotm , b <, sef tit <br /> It . k. <br /> .t► i -n • /��� ..•' ubiCP�l► . 40_� 'V' '. tib .4_ . <br /> _ otylvvu .p At&k,r-it=s +ewe!' .__ .f .iktJzii 0 JP %/VIAI/k --0 <br /> ,,vt try I t-k-e 1, I _ iA4 r a� 4 `t+- <br /> e t � 'Ek�, 11(.1 . <br /> . -• V- t- 140-- A)t4frvt LA9,00 La_ ,t.( r&zc, <br /> c�5 &y - tit► • " ,ria .A `sem _.a • DV Al - ,.•ti, <br /> `f f <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 Ir PAGES, IS TRUTHFUL AND ACCURATE TO THE <br /> BEST OF MY PERSONAL KNOWLEDGE. EACH PAGE AND ALL CORRECTIONS, IF ANY, BEAR MY INITIALS. <br /> I HAVE READ /HAVE BEEN READ [ ] THE FORE OING DECLARATION AND UNDERSTAND THAT THIS <br /> DOCUMENT Y BE USED N A COURT OF LAW. ( 1 - <br /> ..-&.....0 <br /> Ci•-• T SIGNATURE) (OFF Eg414644S SIGNATURE) <br /> Oeff.sett / 1 .9i6C- s?)th- )le / W I <br /> (CITY AND STATE WHERE SIGNED) (D/MrE OF STATEMENT) <br /> Page L of ) (INIT.) <br /> PD-004 Rev 7/2007 <br />