Advance Trespass Request

To Be Included w/ Case File

(DO NOT PROVIDE COPY TO SUSPECT)

PROPERTY OWNER/MANAGEMENT INFORMATION
Last Name:	First Name:	MI:	DOB:
Physical Address:	City:	State:	Zip:
Phone:	Alt Phone:
Email:	Height______ Weight______ Hair Color_______ Eye Color_______

I, ______________________________________, do hereby attest that I am either the property owner or have legal dominion over the following properties/locations/addresses:

____________________________________________________________________________

________________________________________________________________________.

Therefore, I do request that the person identified in section #1 of the attached Notice of Exclusion (NOE) document be trespassed from said property for the period of 1 year (365 days) from the date listed in #6 of the NOE.

_____________________________	________________________	__________

Signature	Title	Date

I certify (or declare) under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.

In addition, I have seen, read, or have had read to me the trespass warning listed in #4 of the NOE and understand the warning as well as the entirety of the NOE document. Therefore I grant the Mill Creek Police Department with the permission to trespass any subject(s) from the above listed property that is there without consent or lawful purpose.

OFFICER INSTRUCTIONS:
INCLUDE COPY IN CASE FILE – DO NOT PROVIDE COPY TO SUSPECT

Completed form can be emailed to mcpdforms@cityofmillcreek.com.