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10 <br /> EVERETT POLICE DEPARTMENT STATEMENT FORM <br /> CASE# DD Zb&93 <br /> i‹u, <br /> STATE ENT OF: rn G(� asT NAME �/ �Fl ST NAME MIDDLE N <br /> 1 <br /> RACESEX DATE OF BIRTH HEIGHT WEIGH EE COLOR HAIR COLOR <br /> 2 41 tcz :f`f'c 10-3 I c( zi`-lJr U <br /> RESIDENCE: STREETADDRESS CITY STATE ZIP <br /> HOME PHONE#: 26b1-314c), e7 WORK/CELL#:"/ � � EMPLOYMENT G/ <br /> ALTERNATE CONTACT(IN CASE OF RELOCATION): <br /> koe, /711/^- gvs eff <br /> lek <br /> 1„, y J r�� I e � (4 TSE <br /> �� ekc 02) ,Z c.c../ 9i/ /�S tea! <br /> tv 50 ireYe52 iv", <br /> Jf\ ,) 0.0.9 iy rs 6/1 < 'Z ? 7 Z"' <br /> `&e-- <br /> '7c-(1/ 1111( L/J nii6C2k, (C X01/ <br /> -11'1,6/11 er(, '/4,e774-64rc'ti,fei/C-e__ 1.(161 <br /> 617,31p7bv,,,L4)c-i„,t.feir j'or <br /> L5 Gc LIGr P f r 0'1 2 JZ lU <br /> �w u• `fit/2 <br /> L, 'J7{/ h' `7 r Gr ct,(h/e6 J't 1 C(a-J1 [( <br /> S <br /> S etc �c 7 r61/2 /454 <br /> any hd ( <br /> THIS STATEMENT WAS WRITTEN ON MY BEHALF BY: :A <br /> I DECLARE UNDER THE PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE <br /> FOREGOING WRITTEN STATEMENT, CONSISTING OF ( 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 R AD [x]/HAVE BEEN READ [ ] THE FOREGOING DECLARATION AND UNDERSTAND THAT THIS <br /> DOCUM/ T MAY BE USED IN A COURT OF LAW. ((1.11- ) <br /> II <br /> (DECLARANT SIGNATURE) ( FFICER ES SS IGNATURE) <br /> Wnik <br /> t <br /> (CI,'"AND STATE W IERE SIGNED) (DAJE OF STATEMENT) <br /> Page ) of ( (INIT.) <br /> PD-004 Rev:7/2007 <br />