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EVERETT POLICE DEWAftTMENT STATEMENT FORM <br />STATEMENT OF: <br />RE9f0�G�E: <br />HOMEPHONEx: <br />CASE p: DD n 7_ _��� <br />��d' � e�a � .}r +— ��/emP t`� � �' �`�— <br />STPEET�ppRESS p ST�IE <br />WORWCELL#: W �S'��Y^�Z% � EMPLOYMENT:� <br />/ <br />CONTACT fIN CASE OF <br />; <br />�C <br />IFIIAJIH1CMtrv1 WAJWKI1ItNUNMYBEHALFBY: <br />I DECLARE UNDER THE PENALTY OF PERJURY UNDER T E 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 KNOW LEDGE. EACH PAGE AN ALL CORRECTIONS, IF ANY, BEAR MY INITIALS. <br />I HAVE READ j(ijTHAVE BEEN READ [�HE FnREGOING DECLARATION AND UNDERSTAND THAT THIS <br />DOCUMENT MAY E-IfSED IN A COURT LAW. �� <br />(OECIA(UNTSICNFTURE) �� ��� <br />i (OfiICER Oq W RNESS SiGNATURE� <br />�vP��e.t+. 1,.� i� <br />(CIttAN STAT[WIIERCSIONEO) <br />r�s� _ �r <br />-L��O-b�7 -- <br />(DATE OF ST�TEMENT) <br />(INIT.) <br />PI>.nl+ R.r ': •:a� <br />G/� <br />