First Name:

Middle Initial:

Last Name:

Date of Birth:

Your Physical Address:

Your Telephone Number

Email:

Confirm Email:

Date of Crime:

Location of Crime:

Problem you are reporting:

Describe what happened:

Suspect Information:

Do you wish to be contacted by a deputy? (Yes or No)

I have read this statement - I certify (declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. (RCW 9A.72.085). I certify I made no request for a lawyer, nor did I request to stop my statement, nor was I told or prompted what to say in this statement.

I Agree