Statement Form

Case No.	_______________________	Page ____ of _____

** Form Must Be Completed in Pen & Signed for Submittal **

Last Name:	First Name:	MI:	DOB:
Physical Address:	City:	State:	Zip:
Phone:	□ home □ work □cell	Alt Phone:	□ home □ work □cell
Email:	Height Weight Hair Color Eye Color
The information contained in this complaint is a public record subject to disclosure under the Washington Public Records Act (RCW 42.56) and may be requested and inspected by any person. The identity of a complainant (reporting party) of a crime may be withheld from public inspection at the Agency’s discretion if the complainant, victim or witness indicates at the time this complaint is filed that disclosure would endanger any person’s life, physical safety, or property. However, if an appeal or a criminal case is filed as a result of this complaint, your identity may be required to be disclosed regardless of a request for it to be withheld. By checking the box below you are indicating that you are requesting non-disclosure and understand the information above. Disclosure of my identity would endanger my life, physical safety, or property or that of another/others. Therefore, pursuant to RCW 42.56.240(2), please DO NOT DISCLOSE my identity except to me, an agent acting on my behalf, or another law enforcement agency.

Statement:

Official Use Only
Officer Signature:
Badge No.	Date:

I certify (or declare) under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.
Signature:
Place signed: Indicate City/ State	Date:

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