Felony Judgment and Sentence (FJS) Page 1 of 11
(First -Time Offender)
(RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9))
Superior Court of Washington
County of
State of Washington , Plaintiff,
vs.
______________________________________,
Defendant. DOB
PCN:
SID:
No .
Felony Judgment and Sentence --
First -Time Offender
(FJS)
[ ] Clerk’s Action Required, 2.1 , 3.2, 4.1, 4.3, 4.7,
5.2, 5.3, 5.5, 5.7, and 5.8
[ ] Defendant Used Motor Vehicle
[ ] Juvenile Decline [ ] Mandatory [ ] Discretionary
I. Hearing
1.1 The court conducted a sentencing hearing this date; the defendant, the defendant's lawyer, and th e (deputy)
prosecuting attorney were present.
II. Findings
2.1 Current Offenses : The defendant is guilty of the following offenses, based upon
[ ] guilty plea (date) ____________ [ ] jury -verdict (date) ____________ [ ] bench trial (date) __________ _:
Count Crime RCW Class Date of
(w/subsection) Crime
Class: FA (Felony -A), FB (Felony -B), FC (Felony -C)
(If the crime is a drug offense, include the type of drug in the second column.)
[ ] Additional current offenses are a ttached in Appendix 2.1a.
The jury returned a special verdict or the court made a special finding with regard to the following:
GV [ ] For the crime(s) charged in Count ____________, domestic violence – intimate partner as defined in
RCW 9A.36.041(4) and RCW 26.50.010(7) was pled and proved .
GV [ ] For the crime(s) charged in Count ____________, domestic violence family or household member was
pled and proved. RCW 26.50.010(6) .
Felony Judgment and Sentence (FJS) Page 2 of 11
(First -Time Offender)
(RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9))
[ ] The defendant has a chemical dependency that has contributed to the offense(s). RCW 9.94A.607.
[ ] Reasonable grounds exist to believe the defendant is a mentally ill person as defined in RCW 71.24.025, and
that this condition is likely to have influenced the offense. RCW 9.94B.080.
[ ] Count ________ is a felon y in the commission of which the defendant used a motor vehicle . RCW46.20.285.
[ ] Counts __________________ encompass the same criminal conduct and count as one crime in determining the
offender score (RCW 9.94A.589).
[ ] Other current convictions listed under different cause numbers used in calculating the offender score are
(list offense and cause number):
Crime Cause Number Court (county & state) DV*
Yes
1.
2.
* DV: Domestic Violence was pled and proved.
[ ] Additional current convictions listed under different cause numbers used in calculating the offender score are
attached in Appendix 2.1b.
2.2 Criminal History (RCW 9.94A.525) :
Crime Date of
Crime
Date of
Sentence
Sentencing Court
(County & State)
A or J
Adult,
Juv.
Type
of
Crime
DV*
Yes
1
2
3
* DV: Domestic Violence was pled and proved.
2.3 Sentencing Data :
Count
No.
Offender
Score
Serious -
ness
Level
Standard
Range (not including enhancements)
Plus
Enhancements*
Total Standard
Range (includ ing enhancements)
Maximum
Term
N/A
N/A
N/A
[ ] Additional current offense sentencing data is attached in Appendix 2.3.
2.4 First -Time Offender Waiver . The court finds that the defendant qualifies for waiver of a standard range
sentence.
2.5 Legal Financial Obligations/Restitution . The court has considered the total amount owing, the
defendant's financial resources and the nature of the burden that payment will impose. (RCW 10.01.160). The
court makes the following specif ic findings:
Felony Judgment and Sentence (FJS) Page 3 of 11
(First -Time Offender)
(RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9))
[ ] The defendant is indigent as defined in RCW 10.101.010(3)(a) -(c) because the defendant:
[ ] receives public assistance [ ] is i nvoluntarily committed to a public mental health facility [ ] receives
an a nnual income , after taxes, of 125 percent or less of the current federal poverty level.
[ ] The defendant is not indigent as definied in RCW 10.101.010(3)(a) -(c).
[ ] The following extraordinary circumstances exist that make restitution inappropriate (RCW
9.94A.753):
________________________________ ________________________________ _________________ .
[ ] The defe ndant has the present means to pay the costs of incarceration. RCW 9.94A.760.
2.6 [ ] Felony Firearm Offender Registration . The defendant committed a felony firearm offense as
defined in RCW 9.41.010, and:
[ ] The defendant should register as a felony firearm offender. The court considered the following factors
in making this determination:
[ ] the defendant’s criminal history.
[ ] whether the defendant has previously been found not guilty by reason of insanity of any offense in
this state or else where.
[ ] evidence of the defendant’s propensity for violence that would likely endanger persons.
[ ] other:_______________________________________________________________________.
[ ] The defendant must register as a felony firearm offender because the offense was committed in
conjunction with an offense committed against a person under the age of 18, or a serious violent
offense, or offense involving sexual motivation as defined in RCW 9.94A.030.
III. Judgment
3.1 The defendant is guilty of the C ounts and Charges listed in Paragraph 2.1 and Appendix 2.1.
3.2 [ ] The court dismisses Counts in
the charging document.
IV. Sentence and Order
It is ordered :
4.1 First -Time Offender Waiver of Standard Sentence . RCW 9.94A.030, RCW 9.94A.650. The
defendant is a first -time offender. The court waives imposition of a sentence within the standard sentence
range and imposes the following sentence:
(a) Confinement . The court sentences the defendant to the following term of total confinement in the
custo dy of :
[ ] the ___________________________________ county jail:
[ ] The defendant was under 18 at the time of the offense and shall be initially placed in the custody of
the Department of Children, Youth, and Families (DCYF):
___________________________ _______days total confinement (up to 90 days). RCW 9.94A.650.
Other:______________________________________________ __________________________________ .
Confinement shall commence immediately unless otherwise set forth here:__________________________
___ ______________________________________________________________________________ ____ .
Credit for Time Served : The defendant shall receive credit for eligible time served prior to sentencing if
that confinement was solely under this cause number. RCW 9.94A. 505. The jail shall compute time
served.
[ ] Partial Confinement . The defendant may serve the sentence, if eligible and approved, in partial
confinement in the following programs, subject to the following conditions: ________________________
__________________________________________________ __________________________________.
[ ] work crew RCW 9.94A.725 [ ] home detention RCW 9.94A.731, .190
[ ] work release RCW 9.94A.731 [ ] electronic monitoring RCW 9.94A.030
Felony Judgment and Sentence (FJS) Page 4 of 11
(First -Time Offender)
(RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9))
[ ] Altern ative Conversion . RCW 9.94A.680. _____________ days of total confinement ordered
above are hereby converted to ___________ hours of community restitution (service) (8 hours = 1 day,
nonviolent offenders only, 30 days maximum) under the supervision of the Department of Corrections
(DOC) to be completed:
[ ] on a schedule established by the defendant's community corrections officer.
[ ] as follows:________________________________________________________________ _____ .
[ ] Conversion of Jail Con finement (Nonviolent and Nonsex Offenses) . RCW 9.94A.680(3). The
county jail is authorized to convert jail confinement to an available county supervised community option, to
reduce the time spent in the community option by earned release credit consisten t with local correctional
facility standards, and may require the offender to perform affirmative conduct pursuant to
RCW 9.94A.607.
[ ] The defendant shall receive credit for time served in an available county supervised community
option prior to sente ncing. The jail shall compute time served.
[ ] Alternatives to total confinement were not used because of: ____________________________
[ ] criminal history [ ] failure to appear (finding required for nonviolent offenders only) RCW
9.94A.680.
(b) Community Restitution (Service) . RCW 9.94A.650. The defendant shall perform ___________
hours of community restitution (service) as approved by the defendant's community corrections officer to be
completed:
[ ] on a schedule established by the defe ndant's community corrections officer.
[ ] as follows:______________________________________________________________________ ___ .
This community restitution is in addition to the ordered total confinement.
4.2 Community Custody . RCW 9.94A.650. The de fendant shall serve _______________ months in
community custody under the supervision of DOC (up to12 months if treatment is ordered and up to 6 months
if treatment is not ordered).
The defendant shall report to the DOC not later than 72 hours after releas e from custody at the address
provided in open court or by separate document. The defendant shall comply with the instructions, rules and
regulations of DOC for the conduct of the defendant during the period of community custody. The defendant
shall obey all laws, perform affirmative acts as required by DOC to confirm compliance with the orders of the
court. The defendant shall comply with any other conditions of community custody stated in this Judgment and
Sentence or imposed by DOC under RCW 9.94A.704 a nd .706 during community custody. While under
supervision, the defendant shall not own, use, or possess firearms or ammunition. The court orders that during
the period of supervision the defendant shall:
[ ] pay all court -ordered legal financial oblig ations.
[ ] notify the community corrections officer in
advance of any change in defendant’s address or
employment.
[ ] report as directed to a community corrections
officer.
[ ] devote time to specific employment or
occupation.
[ ] not possess or consume alcohol.
[ ] not possess or consume controlled substances,
including marijuana, without a valid prescription.
[ ] undergo available treatment for a period not to
exceed one year.
[ ] remain within prescribed geographical boundaries.
[ ] obt ain a mental health evaluation and comply with
recommended treatment.
[ ] obtain a substance use disorder evaluation and
comply with recommended treatment.
Felony Judgment and Sentence (FJS) Page 5 of 11
(First -Time Offender)
(RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9))
The conditions of community custody shall begin immediately unless otherwise set forth here:
________________________________ ________________________________ _______________________ .
Court -Ordered Treatment: If any court orders mental health or substance use disorder treatment, the defendant
must notify DOC and the defendant must release treatment information to DOC for the duration of
incarceration and supervision. RCW 9.94A .562.
4.3 Legal Financial Obligations : The defendant shall pay to the clerk of this court:
JASS /Odyssey CODE
PCV 310 5 $ 500 Victim assessment RCW 7.68.035
PDV 3102 $____________ Domestic Violence (DV) assessment RCW 10.99.080
$ Violation of a DV pr otection order ($15 mandatory fine) RCW 26.50.110
CRC 3403 $ Court costs, including RCW 9.94A.760, 9.94A.505, 10.01.160, 10.46.190
Criminal filing fee $200.00 FRC
Witness costs $ WFR
Sheriff service fees $ SFR/SFS/SFW/ WRF
Jury demand fee $ JFR
Extradition costs $ EXT
Other $
PUB 3225 $ Fees for court appointed attorney RCW 9.94A.760
WFR 3231 $ Court appointed defense expert and other defense costs RCW 9.94A .760
FCM 3303 $ Fine RCW 9A.20.021; [ ] VUCSA chapter 69.50 RCW, [ ] VUCSA
MTH 3337 additional fine deferred due to indigency RCW 69.50.430
CDF 3302 $ Drug enforcement fund of ____________________RCW 9 .94A.760
LDI 3308/FCD 3363
NTF 3338 /SAD 3365 /SDI 3307
CLF 3212 $ Crime lab fee [ ] suspended due to indigency RCW 43.43.690
$ 100 DNA collection fee [ ] suspended . DNA previously collected RCW 43.43.7541
FPV 3335 $ Specia lized forest products RCW 76.48.171
$ Other fines or costs for:
$ Restitution to:
RTN/RJN 3801
$ Restitution to:
$ Restitution to:
(Name and Address --address may be withheld and provided
confidentially to Clerk of the Court’s office.)
$ Total RCW 9.94A.760
[ ] The above total does not include all restitution or other legal financial obligations, which may be set by
later order of the court. An agreed restitution order may be entered. RCW 9.94A.753. A restitution
hearing:
[ ] shall be set by the prosecutor.
[ ] is scheduled for (date).
[ ] The defendant waives any right to be present at any restitution hearin g (sign initials):_____________.
Felony Judgment and Sentence (FJS) Page 6 of 11
(First -Time Offender)
(RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9))
[ ] Restitution Schedule attached.
[ ] Restitution ordered above shall be paid jointly and severally with:
Name of other defendant Cause Number (Victim’s name) (Amount -$)
RJN ________________________________ ________________________________ ____________________
________________________________ ________________________________ _____________________
[ ] The Department of Corrections (DOC) or clerk of the court shall immediately issue a Notice of Payroll
Deduction. RCW 9.94A.7602, RCW 9.94A.760(8).
[ ] All payments shall be made in accordance with the policies of the clerk of the court and on a schedule
established by D OC or the clerk of the court, commencing immediately, unless the court specifically sets
forth the rate here: Not less than $_____ per month commencing_________________________________.
RCW 9.94A.760. (Restitution payments must begin immediately. RCW 9.4 A.750(1).)
The defendant shall report to the clerk of the court or as directed by the clerk of the court to provide financial
and other information as requested. RCW 9.94A.760(7)(b).
[ ] The court orders the defendant to pay costs of incarceration at t he rate of $______________ per day (actual
costs not to exceed $100 per day). ( JLR ) RCW 9.94A.760. (This provision does not apply to costs of
incarceration collected by DOC under RCW 72.09.111 and 72.09.480.)
The restitution obligations imposed in this judgment shall bear interest from the date of the judgment until
payment in full, at the rate applicable to civil judgments. No interest shall accrue on non -restitution obligations
imposed in this judgment. RCW 10.82.090. An award of costs on appeal ag ainst the defendant may be added
to the total legal financial obligations. RCW 10.73.160.
4.4 DNA Testing . The defendant shall have a biological sample collected for purposes of DNA identification
analysis and the defendant shall fully cooperate in the testing. This paragraph does not apply if it is established
that the Washington State Patrol crime laboratory already has a sample from the defendant for a qualifying
offense. RCW 43.43.754.
The facility where the defendant serves the term of confinement shall be responsible for obtaining the sample as
part of the defendant ’s intake process or as soon as practicable .
If further c onfinement is not ordered, t he defendant shall report to ____________________________________
(law enforcement agency) by ______ _______________________ (date/time) to provide a biological sample.
Failure to provide a biological sample is a gross misdemeanor.
[ ] HIV Testing . The defendant shall submit to HIV testing. RCW 70.24.340.
4.5 No Contact :
[ ] The defendant shall not have contact with ________________________________________________
__________________________________________________________ (name/s) including, but not
limited to, personal, verbal, telephonic, written, or contact through a third party until ________ _________
(which does not exceed the maximum statutory sentence).
[ ] The defendant is excluded or prohibited from coming within ______________________ (distance) of:
[ ] _______________________________________________(name of protected person/s)’s [ ] home/
residence [ ] work place [ ] school [ ] (other location/s) ______________________________________
_________________________________________________________________________________, or
[ ] other location _________________________________________ __________________________,
until _______________________ (which does not exceed the maximum statutory sentence).
Felony Judgment and Sentence (FJS) Page 7 of 11
(First -Time Offender)
(RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9))
[ ] A separate Domestic Violence No -Contact Order, Antiharassment No -Contact Order, Stalking No -Contact
Order, or Sexual Assault Protection Order is filed concurrent with this Judgment and Sentence.
4.6 Other :
4.7 Exoneration : The Court hereby exonerates any bail, bond, and/or personal recognizance conditions.
V. Notices and Signatures
5.1 Collateral Attack on Judgment . If you wish to petition or move for collateral attack on this Judgment
and Sentence, including but not limited to any personal restraint petition, state habeas corpus petition, motion to
vacate judgment, motion to withdraw guilty plea, motion for new trial or mot ion to arrest judgment, you must
do so within one year of the final judgment in this matter, except as provided for in RCW 10.73.100.
RCW 10.73.090.
5.2 Length of Supervision . If you committed your offense prior to July 1, 2000, you shall remain under t he
court's jurisdiction and the supervision of the Department of Corrections for a period up to 10 years from the
date of sentence or release from confinement, whichever is longer, to assure payment of all legal financial
obligations unless the court exten ds the criminal judgment an additional 10 years. If you committed your
offense on or after July 1, 2000, the court shall retain jurisdiction over you, for the purpose of your compliance
with payment of the legal financial obligations, until you have comp letely satisfied your obligation, regardless
of the statutory maximum for the crime. RCW 9.94A.760, RCW 9.94A.505(5). The clerk of the court has
authority to collect unpaid legal financial obligations at any time while you remain under the jurisdiction o f the
court for purposes of your legal financial obligations. RCW 9.94A.760(4), RCW 9.94A.753(4).
5.3 Notice of Income -Withholding Action . If the court has not ordered an immediate notice of payroll
deduction in Section 4.1, you are notified that the De partment of Corrections (DOC) or the clerk of the court
may issue a notice of payroll deduction without notice to you if you are more than 30 days past due in monthly
payments in an amount equal to or greater than the amount payable for one month. RCW 9.9 4A.7602. Other
income -withholding action under RCW 9.94A.760 may be taken without further notice. RCW 9.94A.7606.
5.4 Community Custody Violation .
If you are subject to a violation hearing and DOC finds that you committed the violation, you may receive a
sanction of up to 30 days of confinement. RCW 9.94A.633(1).
5.5a Firearms . You may not own, use or possess any firearm, and under federal law any firearm or
ammunition, unless your right to do so is restored by the court in which you are convicted or t he superior
court in Washington State where you live, and by a federal court if required. You must immediately
surrender any concealed pistol license. (The clerk of the court shall forward a copy of the defendant's
driver's license, identicard, or compar able identification to the Department of Licensing along with the date of
conviction or commitment.) RCW 9.41.040, 9.41.047.
5.5b [ ] Felony Firearm Offender Registration . The defendant is required to register as a felony firearm
offender. The specif ic registration requirements are in the “Felony Firearm Offender Registration” attachment.
Delete or cross off if not applicable :
5.6 [ ] Offender Registration . (Unlawful Imprisonment Involving a Minor) RCW 9A.44.128,
9A.44.130, 10.01.200.
1. Genera l Applicability and Requirements : Because this crime involves a sex offense or kidnapping
offense involving a minor as defined in RCW 9A.44.128 , you are required to register.
Felony Judgment and Sentence (FJS) Page 8 of 11
(First -Time Offender)
(RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9))
If you are a resident of Washington, you must register with the sheriff of the county of the state of
Washington where you reside. You must register within three business days of being sentenced unless you
are in custody, in which case you must register at the time of your release with the person designated by
the agency that has ju risdiction over you. You must also register within three business days of your
release with the sheriff of the county of the state of Washington where you will be residing.
While in custody, if you are approved for partial confinement, you must register when you transfer to partial
confinement with the person designated by the agency that has jurisdiction over you. You must also register
within three business days from the end of partial confinement or release from confinement with the sheriff of
the cou nty where you reside.
If you are not a resident of Washington but you are a student in Washington or you are employed in
Washington or you carry on a vocation in Washington, you must register with the sheriff of the county of your
school, place of emplo yment, or vocation. You must register within three business days of being sentenced
unless you are in custody, in which case you must register at the time of your release with the person
designated by the agency that has jurisdiction over you. You must a lso register within three business days of
your release with the sheriff of the county of your school, where you are employed, or where you carry on a
vocation.
2. Offenders Who are New Residents, Temporary Residents, or Returning Washington
Residents : If you move to Washington or if you leave this state following your sentencing or release
from custody but later move back to Washington, you must register within three business days after
moving to this state. If you leave this state following your sentenc ing or release from custody but later while
not a resident of Washington you become employed in Washington, carry on a vocation in Washington, or
attend school in Washington, you must register within three business days after starting school in this state or
becoming employed or carrying out a vocation in this state. If you are visiting and intend to reside or be
present 10 or more days in Washington, then you must register the location where you plan to stay or your
temporary address with the sheriff of ea ch county where you will be staying within three business days of
your arrival.
3. Change of Residence Within State : If you change your residence within a county, you must provide,
by certified mail, with return receipt requested or in person, signed wri tten notice of your change of residence
to the sheriff within three business days of moving. If you change your residence to a new county within this
state, you must register with the sheriff of the new county within three business days of moving. Also w ithin
three business days, you must provide, by certified mail, with return receipt requested or in person, signed
written notice of your change of address to the sheriff of the county where you last registered.
4. Leaving the State or Moving to Another State : If you move to another state, or if you work, carry
on a vocation, or attend school in another state you must register a new address, fingerprints, and
photograph with the new state within three business days after establishing residence, or after beginning to
work, carry on a vocation, or attend school in the new state. If you move out of the state, you must also
send written notice within three business days of moving to the new state or to a foreign country to the
county sheriff with whom you la st registered in Washington State.
5. Travel Outside the United States : If you intend to travel outside the United States, you must
provide signed written notice of the details of your plan to travel out of the country to the sheriff of the
county where you are registered. Notice must be provided at least 21 days before you travel. Notice may
be provided to the sheriff by certified mail, with return receipt requested, or in person.
If you cancel or postpone this travel, you must notify the sheriff with in three days of canceling or
postponing your travel or on the departure date you provide in your notice, whichever is earlier.
If you travel routinely across international borders for work, or if you must travel unexpectedly due to a
family or work eme rgency, you must personally notify the sheriff at least 24 hours before you travel. You
must explain to the sheriff in writing why it is impractical for you to comply with the notice required by
RCW 9A.44.130(3).
Felony Judgment and Sentence (FJS) Page 9 of 11
(First -Time Offender)
(RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9))
6. Notification Requirement When Enrolli ng in or Employed by a Public or Private Institution
of Higher Education or Common School (K -12) : You must give notice to the sheriff of the county
where you are registered within three business days:
i) before arriving at a school or institution of high er education to attend classes;
ii) before starting work at an institution of higher education; or
iii) after any termination of enrollment or employment at a school or institution of higher education.
7. Registration by a Person Who Does Not Have a Fixe d Residence : Even if you do not have a
fixed residence, you are required to register. Registration must occur within three business days of release in
the county where you are being supervised if you do not have a residence at the time of your release fr om
custody. Within three business days after losing your fixed residence, you must send signed written notice to
the sheriff of the county where you last registered. If you enter a different county and stay there for more than
24 hours, you will be requ ired to register with the sheriff of the new county not more than three business days
after entering the new county. You must also report weekly in person to the sheriff of the county where you
are registered. The weekly report shall be on a day specified by the county sheriff's office, and shall occur
during normal business hours. You must keep an accurate accounting of where you stay during the week and
provide it to the county sheriff upon request. The lack of a fixed residence is a factor that may be considered
in determining an offender’s risk level and shall make the offender subject to disclosure of information to the
public at large pursuant to RCW 4.24.550.
8. Application for a Name Change : If you apply for a name change, you must submit a copy o f the
application to the county sheriff of the county of your residence and to the state patrol not fewer than five
days before the entry of an order granting the name change. If you receive an order changing your name, you
must submit a copy of the order to the county sheriff of the county of your residence and to the state patrol
within three business days of the entry of the order. RCW 9A.44.130(7).
5.7 [ ] Department of Licensing Notice : The court finds that Count ________ is a felony in the
commis sion of which a motor vehicle was used. Clerk’s Action –The clerk shall forward an Abstract of
Court Record (ACR) to the DOL, which must revoke the Defendant’s driver’s license. RCW 46.20.285.
5.8 [ ] Department of Licensing Notice – Defendant under ag e 21 only.
Count ________ is (a) a violation of RCW chapter 69.41 [Legend drug], 69.50 [VUCSA], or 69.52
[Imitation drugs], and the defendant was under 21 years of age at the time of the offense OR (b) a violation
under RCW 9.41.040 [unlawful possession o f firearm], and the defendant was under the age of 18 at the
time of the offense OR (c) a violation under RCW chapter 66.44 [Alcohol], and the defendant was under
the age of 18 at the time of the offense, AND the court finds that the defendant previously c ommitted an
offense while armed with a firearm, an unlawful possession of a firearm offense, or an offense in violation
of chapter 66.44, 69.41, 69.50, or 69.52 RCW.
Clerk’s Action –The clerk shall forward an Abstract of Court Record (ACR) to the DOL, wh ich must
revoke the Defendant’s driver’s license. RCW 46.20.265.
5.9 Other :______________________________________________________________________________.
Done in Open Court and in the presence of the defendant this date: ______________________________.
_______________________________________________
Judge /Print Name:
____________________________ ___________________________ ____________________________
Deputy Prosecuting Attorney Attorney for Defendant Defendant
WSBA No. WSBA No.
Print Name: Print Name: Print Name:
Felony Judgment and Sentence (FJS) Page 10 of 11
(First -Time Offender)
(RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9))
Voting Rights Statement : I acknowledge that I have lost my right to vote because of this felony conviction. If I
am registered to vote, my voter registration will be cancelled.
My right to vote is provisionally restored as long as I am not under the authority of DOC (not serving a sentence of
confinement in the custody of DOC and not subject to community custody as defined in RCW 9.94A.030). I must re -
register before voting. The provisional right to vote may be revoked if I fail to comply with all the terms of my legal
financial obligations or an agreement for the payment of legal financial obligations.
My right to vote may be permanently restored by one of the following for each felony conviction: a) a certificate of
dis charge issued by the sentencing court, RCW 9.94A.637; b) a court order issued by the sentencing court restoring
the right, RCW 9.92.066; c) a final order of discharge issued by the indeterminate sentence review board, RCW
9.96.050; or d) a certificate o f restoration issued by the governor, RCW 9.96.020. Voting before the right is restored
is a class C felony, RCW 29A.84.660. Registering to vote before the right is restored is a class C felony, RCW
29A.84.140.
Defendant’s signature: __________________ ____________________________
I am a certified or registered interpreter, or the court has found me otherwise qualified to interpret, in the
_________________________________ language, which the defendant understands. I interpreted this Judgment
and Sente nce for the defendant into that language.
I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct.
Signed at (city) ____________________, (state) _______________, on (date) _____________________ _.
_______________________________________ ____________________________________________
Interpreter Print Name
Felony Judgment and Sentence (FJS) Page 11 of 11
(First -Time Offender)
(RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9))
VI. Identification of the Defendant
SID No. ______________________________________
(If no SID complete a separate Applicant card
(Form FD -258) for State Patrol)
Date of Bir th __________________________
FBI No. ______ ____________________________ Local ID N o. __________________________
PCN No. _____ _____________________________ Other ___ _____________________________
Alias name, DOB: ___ _____________________________________ ___________________________
Race : Ethnicity : Sex :
[ ] Asian [ ] Black [ ] Indian -American Indian or Alaska Native [ ] Hispanic [ ] Male
[ ] Multiracial [ ] Native Hawaiian or Other Pacific Islander [ ] Non -Hispanic [ ] Female
[ ] Refused [ ] White [ ] Unavailable [ ] Refused
[ ] Unknown [ ] Other: [ ] Unknown
Fingerprints : I attest that I saw the defendant who appeared in court affix his or her fingerprints and signature
on this document.
Clerk of the Court, Deputy Clerk, ___________________________ ____ Dated:________________ _
The defendant’s signature :
Left four fingers taken simultaneously
Left
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Right
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Right four fingers taken simultaneously
