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• <br /> 9 <br /> EVERETT POLICE DEPARTMENT STATEMENT FORM <br /> CASE# DD 13 • 2-°& 3 <br /> STATEMENT OF: LAST NAME / FIRST NAME, // MIDDLE NAMESEOLOR /� <br /> X 5./5-4 N / QIGHT EYE Com � HAIR CC-!L/ <br /> RESIDENCE: ZlOLOR <br /> /00 STREET� "DSs6o . �Q� e--f/ clDATE OF BIRTH HEIGHTyTr z4)/1- 9YZ�O, <br /> HOME PHONE#: 12S'351" 7—3C 24—WORK/CELL#:4 $3 2d42-/,' EMPLOYMENT: 9h1EL7 ' <br /> ALTERNATE CONTACT(IN CASE OF RELOCATION): <br /> 5J / d// 6// 3 ,,4 _4P,e)crzii <br /> Ao G-- A- d.0, <br /> b—/O TWA/ �' , f�#e_49/-C<W,c2S cry <br /> Mom/yi d 1-0,4 /it) N/3 1/4-iti <br /> 5 77/11 . 444_ M l/i41/11 <br /> PcIA- /1/1A-c / i Gv/L. e - <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 I 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 ['Si /HAVE BEEN READ [ j THE FO - SING DECLARATION AND UNDERSTAND THAT THIS <br /> DOCUMENT MAY BE USED IN A OURT OF LAW. L.� <br /> / at <br /> (DECLARANT SIGNATURE) (OFFICE ESS I NATU ) <br /> (it/A41- / J// <br /> , <br /> (CrTY AND STATE WHERE SIGNED) (DATE OF STATEMENT) <br /> Page of (INIT.) <br /> PD-004 Rev 7/2007 <br />