Fill and Sign the State Appellate Courtsthe Researching Paralegal Form

Felony Judgment and Sentence (FJS) Page 1 of 10 (Drug Offender Sentencing Alternative) (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 Drug Offender Sentencing Alternative (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 l awyer, 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.) [ ] Additional current offenses are attached in Appendix 2.1a. The defendant is a drug offender who is eligible for the drug offender sentencing alternative and the court determines that the sentencing alternative is appropriate. RCW 9.94A.660. 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 and household member ) was pled and proved. RCW 26.50.010(6) . Felony Judgment and Sentence (FJS) Page 2 of 10 (Drug Offender Sentencing Alternative) (RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9)) [ ] Count _______________________, Violation of the Uniform Controlled Substances Act (VUC SA) , RCW 69.50.401 and RCW 69.50.435, took place in a school, school bus, within 1000 feet of the perimeter of a school grounds or within 1000 feet of a school bus route stop designated by the school district; or in a public park, public transit vehicle, or public transit stop shelter; or in, or within 1000 feet of the perimeter of a civic center designated as a drug -free zone by a local government authority, or in a public housing project designated by a local governing authority as a drug -free zone. [ ] In count ___________ the defendant committed a robbery of a pharmacy as defined in RCW 18.64.011(21), RCW 9.94A.____. [ ] The defendant committed a crime involving the manufacture of methamphetamine, including its salts, isomers, and salts of isomers , when a juvenile was present in or upon the premises of manufacture in Count _____________________________. RCW 9.94A.605, RCW 69.50.401, RCW 69.50.440. [ ] 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 criminal street gang -related felony offense in which the defendant compensated, threatened, or solicited a minor in order to involve that minor in the commission of the offense. RCW 9.94A.833. [ ] Count ____________ is the crime of unlawful possession of a firearm and the defendan t was a criminal street gang member or associate when the defendant committed the crime. RCW 9.94A.702, 9.94A.829. [ ] Count _________ is a felony in the commission of which the defendant used a motor vehicle . RCW46.20.285. [ ] Count __________ inv olves attempting to elude a police vehicle and during the commission of the crime the defendant endangered one or more persons other than the defendant or the pursuing law enforcement officer. RCW 9.94A.834. [ ] Counts __________________ encompass the s ame 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 Num ber 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 Crimi nal 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 4 Felony Judgment and Sentence (FJS) Page 3 of 10 (Drug Offender Sentencing Alternative) (RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9)) 5 *DV: Domestic Violence was pled and proved. [ ] Add itional 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 numbers(s) ___________, a bove, or in appendix 2.2, are one offense for purposes of determining the offender score (RCW 9.94A.525) [ ] The prior convictions listed as numbers(s) ___________, above, or in appendix 2.2, are not counted as points but as enhancements pursuant to RC W 46.61.520 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 * (V) VUCSA in a protec ted zone, (RPh) Robbery of a pharmacy, (JP) Juvenile present, (CSG) criminal street gang involving minor, (AE) endangerment while attempting to elude. [ ] Additional current offense sentencing data is attached in Appendix 2.3. 2.4 [ ] Exceptional Sente nce . The court finds substantial and compelling reasons that justify an exceptional sentence: [ ] below the standard range for Count(s) _______________. [ ] above the standard range for Count(s) _______________. [ ] The defendant and state sti pulate that justice is best served by imposition of the exceptional sentence above the standard range and the court finds the exceptional sentence furthers and is consistent with the interests of justice and the purposes of the sentencing reform act. [ ] Aggravating factors were [ ] stipulated by the defendant, [ ] found by the court after the defendant waived jury trial, [ ] found by jury, by special interrogatory. [ ] within the standard range for Count(s) _________, but served consecutively to Count(s) ____________. Findings of fact and conclusions of law are attached in Appendix 2.4. [ ] Jury’s special interrogatory is attached. The Prosecuting Attorney [ ] did [ ] did not recommend a similar sentence. 2.5 Legal Financial Obligations/R estitution . 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 specific findings: [ ] The defendant is indigent as de fined 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): . Felony Judgment and Sentence (FJS) Page 4 of 10 (Drug Offender Sentencing Alternative) (RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9)) [ ] The defendant has the present means to pay costs of incarc eration. 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 v iolence 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 c ommitted 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 Confinement . The court waives imposition of a sentence within the standard range and imposes the following sentence: (a) Prison -Based Alternative (effective for sentences imposed on or after October 1, 2005). (1) Confinement . 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) (half of the midpoint of the standard range, or 12 months, whichever is greater): _____________________ months of total confinement in the custody of DOC on Count ____________. _______ ______________ months of total confinement in the custody of DOC on Count ____________. _____________________ months of total confinement in the custody of DOC on Count ____________. Confinement shall commence immediately unless otherwise set forth here : _______________________ _________________________________________________________________________________. Work release is authorized, if eligible and approved. Credit for Time Served . The defendant shall receive credit for eligible time served prio r to sentencing if that confinement was solely under this cause number. RCW 9.94A.505. The jail shall compute time served. (2) Community Custody . The defendant shall serve: _____________________ months in community custody on Count ________________. _____________________ months in community custody on Count ________________. _____________________ months in community custody on Count ________________. (One half the midpoint of the standard range.) The defendant shall comply with the community custody conditions in paragraph 4.2. Felony Judgment and Sentence (FJS) Page 5 of 10 (Drug Offender Sentencing Alternative) (RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9)) (3) Additional Term of Community Custody . If the defendant fails to complete, or is administratively terminated from, the drug offender sentencing alternative program, the court imposes a term of 12 months community custody under RCW 9.94A.701 unless community custody is not authorized for the crime. (b) Residential Chemical Dependency Treatment -Based Alternative (effective for sentences imposed on or after October 1, 2005). (1) The defendant shall serve: _________________ __ months in community custody on Count ______________. ___________________ months in community custody on Count ______________. ___________________ months in community custody on Count ______________. (A term equal to one -half of the midpoint of the st andard range or two years, whichever is greater) under the supervision of the Department of Corrections (DOC), on the condition that the defendant enters and remains in residential chemical dependency treatment certified under chapter 70.96A RCW for ______ ________________________ months. (2) The defendant shall comply with the community custody conditions in paragraph 4.2. DOC shall make chemical dependency assessment and treatment services available to the defendant during the term of community custody , within available funding. (3) The defendant shall appear in person or by telephone at a progress hearing and a termination hearing to be set by the court at a later date. 4.2 Community Custody Conditions . RCW 9.94A.660. The defendant shall report to DOC not later than 72 hours after sentencing or release 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 perform affirmative acts as required by DOC to confirm compliance with the orders of the court. The defendant shall not use illegal controlled substances. The defendant shall comply with any other conditio ns of community custody stated in this Judgment and Sentence or imposed by DOC under RCW 9.94A.704 and .706 during community custody. While under supervision the defendant shall not not own, use, or possess firearms or ammunition. The court orders that d uring the peiod of supervision the defendant shall: (a) Undergo and successfully complete a substance use disorder treatment program approved by the Department of Social and Health Services. (b) Undergo urinanalysis or other testing to monitor drug -free status. [ ] The defendant shall pay the statutory rate to DOC, while on community custody, to offset the cost of urinanalysis. (c) Additional conditions (choose at least three): [ ] pay all court -ordered legal financial obligations. [ ] report as directed to a community corrections officer. [ ] notify the court or community corrections officer in advance of any change in defendant’s address or employment. [ ] remain within or outside of prescribed geographical boundaries. [ ] devote time to specific employment or training [ ] perform community restitution (service) work. [ ] stay out of areas designated by the judge. [ ] not possess or consume alcohol. [ ] not possess or consume controlled substances, including marijuan a, without a valid prescription. [ ] obtain a mental health evaluation and comply with recommended treatment. Court Ordered Treatment: If any court orders mental health or substance use disorder treatment, the defendant must notify DOC and the defendan t must release treatment information to DOC for the duration of incarceration and supervision. RCW 9.94A.562. Other Conditions: Felony Judgment and Sentence (FJS) Page 6 of 10 (Drug Offender Sentencing Alternative) (RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9)) . 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 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 ap pointed 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 additional MTH 3337 fine deferred due to indigency RCW 69.50.430 CDF 3302 $ Drug enforcement fund of ____________________ RCW 9.94A.760 LDI 3308/FCD3363 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 $ Specialized 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 Cle rk 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 entere d. 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 -$) Felony Judgment and Sentence (FJS) Page 7 of 10 (Drug Offender Sentencing Alternative) (RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9)) RJN ________________________________ ________________________________ ____________________ ________________________________ ________________________________ ____________________ [ ] The Department of Corrections (DOC) or clerk of the court shall immediately issue a No tice 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 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 orders the defendant to pay costs of incarceration at the rate of $_________ per day (actual costs not to exceed $100 per da y). ( 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. RC W 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. 4.4 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 Was hington 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) 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 doe s not exceed the maximum statutory sentence). [ ] 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. Felony Judgment and Sentence (FJS) Page 8 of 10 (Drug Offender Sentencing Alternative) (RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9)) 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 motion to arrest judgment, you must do so within one year of the fin al 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 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 committe d 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 max imum for the crime. RCW 9.94A.760 and 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 of the court for purposes of your legal financial obligations. RCW 9.94A.760(4) and 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 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.7 60 may be taken without further notice. RCW 9.94A.7606. 5.4 Community Custody Violation . (a) Prison -based alternative: If DOC finds that you willfully violated the conditions of the drug offender sentencing alternative program, DOC may reclassify you to serve the remaining balance of the original sentence. (b) Residential chemical dependency treatment -based alternative: If the court finds that you willfully violated the conditions of the drug offender sentencing alternative, the court may order you to ser ve a term of total confinement equal to one -half the midpoint of the standard range or a term of total confinement up to the top of the standard range. The court may also impose a term of community custody. (c) In any case, if you are subject to a violati on 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). (d) In any case, if you have not completed your maximum term of total confinement and you are subject to a violation h earing 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 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 the superior court of Washington State where you live, and by a federal court if required. You must immediately surrender any conceale d 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, 9.41.047. 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 Registration” attachment. 5.6 Reserved. Felony Judgment and Sentence (FJS) Page 9 of 10 (Drug Offender Sentencing Alternative) (RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9)) 5.7 [ ] Department of Licensin g 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 4 6.20.285. 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 t he 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 t ime of the offense, 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 forward an Abstract of Court Record (ACR) to the DOL, which must revoke the Defendant’s driver’s license. RCW 46.20.265. 5.9 Other : ______________________________________________________________________________. Done in Open Court and in t he presence of the defendant this date: ______________________________ _. _______________________________________________ Judge /Print Name: _____________________________ ____________________________ _____________________________ Deputy Prosecuting Attorn ey 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 registra tion 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 on e of the following 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 i ndeterminate sentence 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 restored is a cla ss 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, w hich the defendant 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) ________ ____________, (state) _______________, on (date) ______________________. _______________________________________ ____________________________________________ Interpreter Print Name Felony Judgment and Sentence (FJS) Page 10 of 10 (Drug Offender Sentencing Alternative) (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 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 Thumb Right Thumb Right four fingers taken simultaneously