Statement Form Continued

Case No.	_______________________	Page ____ of _____

Last Name:	First Name:	MI:	DOB:

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.