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1 of SNOHOMISH COUNTY SUPERFORM <br /> AGENCY: DEPUTY/OFFICER/TROOPER: CASE#: <br /> C ❑ REFERRAL ® BOOKING EVERETT PD WALLACE,N 1334 DD11-24894 <br /> 0 JUV# REF# <br /> ❑SUPERIOR ❑JUVENILE <br /> 1 DISTRICT/MUNI COURT: <br /> ❑SOUTH; ❑EVERGREEN; ❑CASCADE; ®EVERETT; ❑OTHER: <br /> DATE AND TIME OF ARREST: BOOKING/ADMISSION DATE/TIME: RELEASE DATE/TIME: IDENTITY IN DOUBT? NO <br /> �' <br /> 12/2/110722 / �/ Hours <br /> GO . EXPLAIN <br /> . Interpreter needed?NO <br /> I'd Lang <br /> SEX: RACE: HOT: WGT: HAIR: EYES: STATE: CDL? SSN#: <br /> - M W 606 240 BRO BRO WA NO <br /> vg <br /> CITY: STATE: ZIP. <br /> ,,3 <br /> ..'..:.. HOME PHONE: OTHER PHONE: ALIAS(S)/AKA(S) GANG AFFILIATION <br /> '' EMPLOYER: CITY: W/PHONE: SOURCE OF LKA&EMPLOYER INFO <br /> FATHER ADDRESS: CITY: 1 ST: ZIP: HOME PHONE: <br /> a - MOTHER ADDRESS: CITY: ST. ZIP HOME PHONE. <br /> C y STEP: 0 MOTHER ❑FATHER ADDRESS: CITY: ST. Z1P. HOME PHONE <br /> GUARDIAN/FOSTER/DSHS ADDRESS: CITY: ST: ZIP. PHONE <br /> CD <br /> q <br /> FATHER'S EMPLOYER: WORK NUMBER: MOTHER"S EMPLOYER. WORK NUMBER <br /> v <br /> PARENTS,GUARDIANS,CUSTODIANS NOTIFIED: HOW. <br /> DETENTION <br /> • NOTIFICATION BY WHOM: WHY NOT? <br /> (Youti Centerline Only) • <br /> • <br /> f ... VEHICLE LICENSE NO. STATE: EXPIRES: VEH YR.: MAKE: MODEL STYLE. COLOR <br /> I. <br /> P <br /> C%9 TRAILER#1 LICENSE: STATE: EXPIRES: TR.YR: TRAILER#2 LICENSE. STATE: EXPIRES: TR YR <br /> Cl - OWNER/COMPANY IF OTHER THAN DRIVER: ADDRESS: CITY: STATE. ZIP: <br /> 1 y.c <br /> ACCIDENT: BAC READING: COMMERICAL VEHICLE: HAZMAT: EXEMPT VEHICLE: <br /> NO NR R I F DYES ONO DYES ❑NO CI FARM OR V. OFIRE ❑OTHER: <br /> SUICIDAL? NO EXPLAIN: MENTAL ISSUES? NO EXPLAIN: <br /> R <br /> IDOES THE ARRESTEE HAVE ANY CHRONIC HEALTH PROBLEMS OR CONTAGIOUS DISEASES? NO EXPLAIN: <br /> IS THE ARRESTEE INJURED AT THIS TIME?NO EXPLAIN: <br /> WAS THE ARRESTEE INVOLVED IN A METHAMPHETAMINE LAB OPERATION?NO EXPLAIN: <br /> SUSPECT' <br /> DATA '`'' NUMBER OF CO-SUSPECTS: NAMES: <br /> OFFENSE LOCATION: CTAT: STATE: DATE AND TIME OF OFFENSE: <br /> C 1122 BROADWAY AVE 211 EVERETT WA 12/1/11 0722 <br /> ARREST LOCATION(IF DIFFERENT): WERE DRUGS INVOLVED IN THIS INCIDENT?YES WAS ALCOHOL INVOLVED IN THIS INCIDENT?NO <br /> YES IF YES,LIST DRUG(S)TYPE:METH EXPLAIN: <br /> CHARGE: (i.e.;Assault 4) • • • • COURT WDM RCW,Municipal or County Warrant or <br /> � nFOF Q■ CLASS ARREST Codc(I.E.9A.36.041) Citation Il Bail <br /> 0.31 0 PDP EVT M M ❑ EMC 10.35.020 12.101SVI ' U $500 <br /> 2 0 MAKING FALSE STATEMENTS EVT M M 0 EMC 10.12.190 12.01$144L% $1000 <br /> 3 DV <br /> 0 BAIL JUMPING SOU FEL ® 1110542 s25000 <br /> 4 DY HARASSMENT SOU FEL ® 118733 sNO <br /> SS NOTIFY ON RELEASE? IF UNABLE TO CONTACT, IF DV.REQUEST N.C.ORDER? FIREARMS IN HOME? PRIOR UNREPORTED VIOLENCE? CHILDREN PRESENT? <br /> YES/NO NOTIFY 911? YES/NO YES/NO YES/NO YES/NO AGES: <br /> I ° VICTIM NAME: LAST FIRST MIDDLE DATE OF BIRTH: PHONE: ALT.PHONE: <br /> >i <br /> VICTIM'S ADDRESS. CITY: STATE. ZIP: <br /> 1 <br /> SUSPECT RELATIONSHIP TO VICTIM: EMERGENCY/ALTERNATE CONTACT: EMERGENCY/ALTERNATE CONTACT PHONE <br /> C7 <br /> (1,.; ,.. GUARDIAN NAME AND PHONE NUMBER(IF VICTIM IS A MINOR): NEXT OF KIN–NAME AND PHONE NUMBER(IF VICTIM IS DECEASED): <br /> Rev.08/03/2010 <br />