Duvall Police Department
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Rev 03/20 Form # S4
Case # _____________
Date: ________________ Time: ___________ Place: ____________________________________________
The following is the true and correct statement of:
__________________________________________________ DOB: ___________________________
Name: ( First M.I. Last)
Address: ______________________________________ City: ______________ State: ___ ZIP: __________
Home: ____________________________________ Work: _______________________________________
Employer / School: ________________________________ City: ____________ State: _____ ZIP: ________
I certify under the penalty of perjury under the laws of the State of Washington that my statement is true and
correct and maybe used in a court of law.
Signed: ____________________________________ Witness: ____________________________________
Officer: ____________________________________ I.D. # : ______________________________________
Duvall Police DepARTMENT
Rev 03/20 Form # S4
Additional Information Sheet Case # ______________
I certify, or declare, under the penalty of perjury under the laws of the State of Washington that the
foregoing is true and correct. (9A.72.085)
Signed: Date:
Officer: ____________________________________ I.D. # : ___________________________________
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