Notice of Exclusion

Case No.	_______________________

1. ISSUED TO:

_______________________________________________________________	___________________

Last	First	MI	Date of Birth

Street Address	City	State	Zip Code

Race: ____________	Sex: _____ Height: ______ Weight: ______ Eyes: ______ Hair: _____

2. LOCATION(S) OF EXCLUSION: _____________________________________________________

3. REASON(S0 FOR EXCLUSION: _____________________________________________________

4. TRESPASS WARNING: You are hereby notified that you are no longer licensed, invited or otherwise privileged to enter or remain in or upon the locations listed in #2. The trespass will remain in effect for a period of 1 year (365 days) from the date listed in #6. If you return to this address without specific permission from the property owner, or person with legal dominions over the property, you may be subject to arrest under RCW 9A.52.070, Criminal Trespass in the First Degree. You are also notified that entering the property, in and of itself is a crime, and no other crime need take place. I have read or have had read to me the Trespass Warning contained within this document and I understand the warning.

Signature of Suspect

5. Authorized Signature: I, ____________________________________________, do hereby attest that I am either the property owner or have legal dominion over the property / address listed in #2, and do request that the person identified in #1 be trespassed from said property for the period of 1 year (365 days) from the date listed in #6.

___________________________________	_____________________________	___________

Signature	Title	Date

6. DATE OF ISSUANCE: _________________________________

__________________________________________	_______	________________

Signature of Witness Officer (If Applicable)	ID#	Date