Felony Judgment and Sentence (FJS) (SSOSA) Page 1 of 14
(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 --
Special Sex Offender Sentencing Alternative
(FJS)
[ ] Cler k’s Action Required, para 2.1, 4.1, 4.3a, 4.3b,
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 the (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.)
[ ] Add itional current offenses are attached in Appendix 2.1a.
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) charg ed in Count ____________, domestic violence – family or household member was
pled and proved. RCW 26.50.010(6) .
The defendant is a sex offender who is eligible for the special sex offender sentencing alternative and the court
determines that the sentencin g alternative is appropriate. RCW 9.94A.670.
The Prosecuting Attorney [ ] did [ ] did not recommend a special sex offender sentencing alternative.
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(RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9)
[ ] The defendant is a sex offender subject to indeterminate sentencing under RCW 9.94A.507 .
The jury returned a special verdict or the court made a special finding with regard to the following:
[ ] The defendant used a firearm in the commission of the offense in Count ______________. RCW 9.94A.825,
9.94A.533.
[ ] The defendant used a deadly weapon other than a firearm in committing the offense in Count ____________
_______________________. RCW 9.94A.825, 9.94A.533.
[ ] The defendant engaged, agreed, offered, attempted, solicited another, or conspired to engage a victim of child
rape or child mol estation in sexual conduct in return for a fee in the commission of the offense in Count _____.
RCW 9.94A.839.
[ ] In count _____________ an internet advertisement in which the victim of the crime was described or depicted
was instrumental in facilitati ng the commission of the crime. RCW 9.68A.100, RCW 9.68A.101, or
RCW 9.68A.102, Laws of 2013, ch. 9, §1.
[ ] The offense was predatory as to Count ______________. RCW 9.94A.836.
[ ] The victim was under 15 years of age at the time of the offense i n Count ________________ RCW 9.94A.837.
[ ] The victim was developmentally disabled, mentally disordered, or a frail elder or vulnerable adult at the time of
the offense in Count ________________. RCW 9.94A.838, 9A.44.010.
[ ] The defendant acted wi th sexual motivation in committing the offense in Count_________. RCW 9.94A.835.
[ ] This case involves kidnapping in the first degree, kidnapping in the second degree, or unlawful imprisonment
as defined in chapter 9A.40 RCW, where the victim is a min or and the offender is not the minor’s parent. RCW
9A.44.130.
[ ] In count ___________ the defendant committed a robbery of a pharmacy as defined in RCW 18.64.011(21),
RCW 9.94A.____.
[ ] In Count ______________ the defendant has been convicted of as saulting a law enforcement officer or other
employee of a law enforcement agency who was performing his or her official duties at the time of the assault,
as provided under RCW 9A.36.031, and the defendant intentionally committed the assault with what appe ared to
be a firearm . RCW 9.94A.831, 9.94A.533.
[ ] Count ________ is a felony in the commission of which the defendant used a motor vehicle . RCW46.20.285.
[ ] 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.
[ ] Counts __________________ encompass the same cri minal 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 Cou rt (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.
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(RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9)
2.2 Criminal H istory (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
4
5
* DV:Domestic Violence was pled and proved.
[ ] Additio nal criminal history is attached in Appendix 2.2.
[ ] The defendant committed a current offense while on community placement/community custody (adds one point
to score). RCW 9.94A.525.
[ ] The prior convictions listed as number(s) ___________, above , or in appendix 2.2, are one offense for purposes
of determining the offender score (RCW 9.94A.525).
2.3 Sentencing Data :
Count
No.
Offender
Score
Serious -
ness
Level
Standard
Range (not including enhancements)
Plus
Enhancements*
Total Standard
Range (including enhancements)
Maximum
Term
* (F) Firearm, (D) Other deadly weapons, (RPh) Robbery of a pharmacy, (SM) Sexual motivation, RCW
9.94A.533(8), (SCF) Sexual conduct with a child for a fee, RCW 9.94A.533(9), (ALF) assaul t law enforcement
with firearm, RCW 9.94A.533(12).
[ ] Additional current offense sentencing data is attached in Appendix 2.3.
For violent offenses, most serious offenses, or armed offenders, recommended sentencing agreements or plea
agreements are [ ] attached [ ] as follows: ______________________________________________________.
2.4 Reserved.
2.5 Legal Financial Obligations/Restitution . The court has considered the total amount owing, the
defendant's financial resources and the nature of the burd en that payment will impose. (RCW 10.01.160). The
court makes the following specific findings:
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(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) bec ause the defendant:
[ ] receives public assistance [ ] is i nvoluntarily committed t o 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 circums tances exist that make restitution inappropriate (RCW
9.94A.753):
________________________________ ________________________________ ________________
[ ] The defendant has the present means to pay 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 elsewhere.
[ ] 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 Counts 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 Special Sex Of fender Sentencing Alternative . RCW 9.94A.670. The court imposes the
following:
Sentence . A term of total confinement in the custody of the Department of Corrections (DOC):
[ ] 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):
Determinate Sentence:
months/days on Count ; months/days on Count ;
months/days on Count ; months/days on Count .
Indeterminate Sentence – Qualifying Sex Offenses o ccuring on or after 9 -1-2001. RCW
9.94A.507:
Count _____: Minimum Term : ________ months/days; Maximum Term : _____ years/life.
Count _____: Minimum Term : ________ months/days; Maximum Term : _____ years/life.
Count _____: Minimum Term : ______ __ months/days; Maximum Term : _____ years/life.
Count _____: Minimum Term : ________ months/days; Maximum Term : _____ years/life.
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(RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9)
The above terms for Counts ______________ are consecutive / concurrent .
The above terms shall run [ ] consecutive [ ] concurrent with cause No.(s)
The above terms shall run [ ] consecutive [ ] concurrent to any previously imposed sentence not
referred to in this order.
Sentence Is Suspended . The court suspends the execution of this sentence and imposes the
following conditions of the suspended sentence:
(a) [ ] Confinement. Defendant shall serve a term of confinement as follows, commencing:
[ ] immediately, [ ] (date): by a.m./p.m.:
days/months on Count ; days/months on Count ;
days/months on Count ; days/months on Count .
This term shall be served in:
[ ] The terms of confinement in Counts are consecutive / concurrent .
This sentence shall run consecutive / concurrent with the sentence(s) in cause No.(s)
, and consecutive / concurrent with any other sentence.
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.
[ ] Jail term is satisfied and defendant shall be released under this cause.
For crimes occuring on or after 7/1/05, the defendant is ineligible for earned early release under RCW
9.92.151 during the term of confinement imposed under paragraph 4.1(a).
(b) Commu nity Custody. (Term to be imposed for each count.)
Defendant is placed on community custody for:
[ ] (determinate sentence ) Count(s) :
[ ] the length of the suspended sentence (if greater than three years), or
[ ] three years.
(The longer of the two terms must be imposed.)
[ ] (indeterminate sentence - qualifying sex offenses occurring on or after 9 -1-2001)
Count(s) :
the length of the maximum sentence imposed.
Community custody shall commence immediately but is tolled during any term of confinem ent. The
defendant shall report to the DOC within 72 hours of release from confinement and shall comply with all
rules, regulations and requirements of the DOC, any other conditions stated in this Judgment and
Sentence, and any conditions of the Indetermi nate Sentence Review Board, if applicable. The defendant
shall comply with the community custody conditions in paragraph 4.2.
(c) Treatment . The defendant shall undergo sex offender treatment as follows, for a period of:
[ ] five years (crimes committ ed on or after 7/1/05), or
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(RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9)
[ ] three years (crimes committed prior to 7/1/05), or
[ ] months (up to five years for crimes committed on or after 7/1/05, up to 3 years for
crimes committed before 7/1/05);
and enter, make reasonable progress in, and s uccessfully complete a specialized program for sex
offender treatment with
[ ] The court finds that the defendant’s sex offender treatment provider should be the same person as
the person who examined the defendant, as it is in the best interests of the victim, and successful
treatment of the offender would be otherwise impractical.
Defendant shall abide by all conditions of treatment and shall not change sex offender treatment
provider without prior court approval.
(d) Annual Progress Review Heari ng(s) are set before this court for:
1) , 20 , at ;
2) , 20 , at ;
3) , 20 , at ;
4) , 20 , at ;
The defendant will receive no further notice of these hearings and his/her failure to appear may result in
a bench warrant for his/her arrest.
(e) Termination Hearing . A treatment termination hearing is scheduled for ___________________
______________________________________________________ (date) (three months prior to
anticipated date for completion of treatment). RCW 9.94A.670(6).
(f) Revo cation of Suspended Sentence . At any time during the period of community custody, if the
defendant violates the conditions of the suspended sentence or the court finds that the defendant is
failing to make satisfactory progress in treatment, the court may revoke the suspended sentence and
order execution of the sentence, with credit for any confinement served during the period of community
custody, RCW 9.94A.670.
4.2a Community Custody Conditions . The defendant shall comply with all rules, regulations an d
requirements of DOC and shall perform affirmative acts as required by DOC to confirm compliance with the
orders of the court. While under supervision, the defendant shall not own, use, or possess firearms or
ammunition. For sex offenders sentenced unde r RCW 9.94A.709, the court may extend community custody up
to the statutory maximum term of the sentence. The defendant shall comply with the following conditions
unless otherwise ordered by the court:
(1) report as directed to the court and to a commun ity corrections officer.
(2) abide by any additional conditions of community custody imposed by DOC under RCW 9.94A.704 and
.706.
(3) inform DOC of court -ordered treatment upon request by the department.
(4) disclose the fact of supervision to any me ntal health or substance use disorder treatment provider.
(5) comply with the following specific prohibitions and affirmative conditions relating to known precursor
activities or behaviors:
(6) remain within these geographical boundaries:
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(RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9)
(7) obtain and maintain DOC approved employment.
(8) notify the community corrections officer prior to any change in the defendant’s address or employment.
(9) perform ____________________ hours of community restitution (service) as approved by defendant's
community corrections officer to be completed:
[ ] as follows: ________________________________ ________________________________ ________
[ ] on a schedule established by the defendant's community corrections officer. RCW 9.94A.
(10) pay all legal financial obligations.
(11) pay the supervision fee assessment.
(12) reimbur se the victim for the cost of any counseling required as a result of the defendant’s crime, as
follows:
(13) submit to electronic monitoring if imposed by DOC.
If applicable:
(14) [ ] shall not reside within any community protection zone (inside 880 f eet of the facilities and grounds of
a public or private school). RCW 9.94A.030.
(15) [ ] shall not serve in any paid or volunteer capacity where defendant has control or supervision of minors
under the 13 years of age.
(16) comply with the following cr ime -related prohibitions:
[ ] not possess or consume alcohol.
[ ] not possess or consume controlled substances, including marijuana, without a valid prescription.
[ ] obtain a mental health evaluation and comply with recommended treatment.
[ ] obtain a substance use disorder evaluation and comply with recommended treatment.
[ ] participate in an education program about the negative costs of prostitution.
[ ]
Other conditions : ________________________________ ________________________________ __________
________________________________ ________________________________ ________________________
________________________________ ________________________________ ________________________
Court -Ordered Treatment: If any court orders mental health or s ubstance 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.
4.2b Community Custody Upon SSOSA Revocation :
Determinate Senten ce
[ ] For Count(s) ____________, the court further imposes the following additional term of Community
Custody upon revocation of this suspended sentence: a period of 36 months. The defendant will be
required to comply with the conditions of Community Custody, in section 4.1(b) and section 4.2(a) of this
order, and any other conditions imposed by the court.
Indeterminate Sentence
[ ] For Count(s) ____________, the court further imposes the following additional term of Community
Custody upon revocatio n of this suspended sentence: for any period of time the defendant is released from
confinement before the expiration of the maximum sentence. Unless a condition is waived by the court, the
defendant will be required to comply with any conditions imposed by the court and the Department of
Corrections pursuant to RCW 9.94A.701 -.704, and section 4.2(a) of this order. The defendant will also be
required to comply with all conditions imposed by the Inderterminate Sentence Review board. RCW
9.94A.507 and RC W 9.95.420 - .435.
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(RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9)
4.3a 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
$ Viola tion of a DV protection 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 c osts RCW 9.94A.760
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 $ Specialized forest products RCW 76.48.1 71
PPI 3405 $ Trafficking/Promoting prostitution/Commercial sexual abuse of minor fee (may be
reduced by no more than two thirds upon a finding of inability to pay.)
RCW 9A.40.100, 9A.88.120, 9.68A.105
EXM 3233 $ Fee for Possession of depictions of a m inor engaged in sexually explicit conduct
($1,000 for each separate conviction) RCW 9.68A.070.
$ 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 hearing (sign initials):_____________
[ ] Restitution Schedule attached.
[ ] Restitution ordered above shall be paid jointly and severally with:
Name of other defendant Cause Number (Victim’s name) (Amount -$)
RJN ________________________________ ________________________________ ____________________
________________________________ ________________________________ ____________________
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(RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9)
[ ] 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 th e clerk of the court and on a schedule
established by DOC 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 9.4A.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 o rders the defendant to pay costs of incarceration at the 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 7 2.09.480.)
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 ju dgment. RCW 10.82.090. An award of costs on appeal against the defendant may be added
to the total legal financial obligations. RCW 10.73.160.
4.3b [ ] Electronic Monitoring Reimbursement . The defendant is ordered to reimburse
______________________ __________________ (name of electronic monitoring agency) at
_________________________________________________________, for the cost of pretrial electronic
monitoring in the amount of $______________________.
4.4 DNA Testing . The defendant shall have a b iological 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 t he 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) i ncluding, 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).
[ ] A separate Dome stic 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.
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4.6 Other :
4.7 Exoneration : The Court her eby 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 per sonal restraint petition, state habeas corpus petition, motion to
vacate judgment, motion to withdraw guilty plea, motion for new trial or motion to arrest judgment, you must
do so within one year of the final judgment in this matter, except as provided fo r 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 the
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 extends 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 completely satisfied your obligation, regardless
of the statutory maximum for the crime. RCW 9.94A.760 and RCW 9.94A.5 05(5). The clerk of the court has
authority to collect unpaid legal financial obligations at any time while you remain under the jurisdiction of the
court for purposes of your legal financial obligations. RCW 9.94A.760(4) and RCW 9.94A.753(4).
5.3 Notic e 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 Department 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 9.94A.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 .
(a) 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).
(b) If you have not completed your maximum t erm of total confinement and you are subject to a violation hearing
and DOC finds that you committed the violation, DOC may return you to a state correctional facility to serve up to
the remaining portion of your sentence. RCW 9.94A.633(2)(a).
5.5a Firear ms . 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 the superior
court in Washington State where you live, and by a federal cou rt 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 comparable identification to the Department of Licensing along with the date of
conviction or commitment.) RCW 9.41.040 and RCW 9.41.047.
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5.5b [ ] Felony Firearm Offender Registration . The defendant is required to register as a felony firearm
offender. The specific registration requirements are in the “Felony Firearm Offender Regis tration” attachment.
5.6 Sex and Kidnapping Offender Registration . RCW 9A.44.128, 9A.44.130, 10.01.200.
1. General Applicability and Requirements : Because this crime involves a sex offense or
kidnapping offense involving a minor as defined in RCW 9 A.44.128 , you are required to register.
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 cu stody, 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 also register within three business days of your release with
the sheriff of the county of the state of Wa shington 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 county 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 employment, or vocation. You must register within three business days of being sentenced unless you are in
custody, in which case you must regist er at the time of your release with the person designated by the agency
that has jurisdiction over you. You must also register within three business days of your release with the sheriff
of the county of your school, where you are employed, or where you c arry 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, y ou must register within three business days after moving to this
state. If you leave this state following your sentencing or release from custody but later while not a resident of
Washington you become employed in Washington, carry on a vocation in Washing ton, 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 each 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 written notice of your change of residence to
the sheriff within three business days of moving. If you change your residence to a new count y within this state,
you must register with the sheriff of the new county within three business days of moving. Also within 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 a ddress, 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 n otice within three business days of moving to the new state or to a foreign country to the county
sheriff with whom you last registered in Washington State.
5. Travel Outside the United States : If you intend to travel outside the United States, you mu st
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 within three days of canceling or postponing
your travel or on the departure date you provide in your notice, whichever is earlier.
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(RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9)
If you travel routinely across international borders for work, or if you must travel unexpectedly due to a
family or work emergency, 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) .
6. Notification Requirement When Enrolling in or Employed by a Public or Private
Institution of Higher Education or Common School (K -12) : You must give notice to the she riff of
the county where you are registered within three business days:
i) before arriving at a school or institution of higher education to attend classes;
ii) before starting work at an institution of higher education; or
iii) after any termination of en rollment or employment at a school or institution of higher education.
7. Registration by a Person Who Does Not Have a Fixed Residence : Even if you do not have a
fixed residence, you are required to register. Registration must occur within three busi ness days of release in
the county where you are being supervised if you do not have a residence at the time of your release from
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 required to register with the sheriff of the new county not more than three business days
after entering the new county. You must al so 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 of the
application to the county sheriff of the county of your residence and to the state patrol not fewer than five days
befor e 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
commission 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.
Findings for DUI, Physical Control, Felony DUI or Physical Control :
[ ] Within two hours after driving or being in physical control of a vehicle, the defendant had an alcohol
concentra tion of breath or blood (BAC) of ____ .
[ ] No BAC test result.
[ ] BAC Refused. The defendant refused to take a test offered pursuant to RCW 46.20.308.
[ ] Drug Related. The defendant was under the influence of or affected by any drug.
[ ] THC level was _____ within two hours after driving.
[ ] Passenger under age 16. The defendant committed the offense while a passenger under the age of sixteen
was in the vehicle.
Vehicle Info .: [ ] Commercial Veh.; [ ] 16 Passenger Veh.; [ ] Hazmat Veh.
5.8 [ ] Department of Licensing Notice – Defendant under age 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 of 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 offen se, AND the court finds that the defendant previously committed 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 f orward an Abstract of Court Record (ACR) to the DOL, which must
revoke the Defendant’s driver’s license. RCW 46.20.265
Felony Judgment and Sentence (FJS) (SSOSA) Page 13 of 14
(RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9)
5.9 Other : ____________________________________________________________________________
Done in Open Court and in the presence of th e defendant on this date: ______________________________
_______________________________________________
Judge /Print Name:
_____________________________ ____________________________ ___________________________
Deputy Prosecuting Attorney Attorney for Defendant Defendant
WSBA No. WSBA No.
Print Name: Print Name: Print Name:
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 can celled.
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 v oting. 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 followi ng for each felony conviction: a) a certificate of
discharge 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 sen tence review board, RCW
9.96.050; or d) a certificate of 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 estored 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 defenda nt understands. I interpreted this Judgment
and Sentence 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) ____________________, (s tate) _______________, on (date) ______________________.
_______________________________________ ____________________________________________
Interpreter Print Name
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(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 Birth __________________________
FBI No. __________________________________ Local ID No. __________________________
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 o r her fingerprints and signature
on this document.
Clerk of the Court, Deputy Clerk, _______________________________ Dated:_________________
The defendant’s signature :
Left four fingers taken simultaneously
Left
Thumb
Right
Thumb
Right f our fingers taken simultaneously
