Fill and Sign the Statement on Plea of Guilty Offender Registration Attachment Form

Sta te m ent o n P le a o f G uilt y ( “O ffe nder R eg.” A tta ch m ent) - Page 1 of 2CrR 4.2(g) (1 2/2 015) R CW 1 0.0 1.2 00, 9 A .4 4.1 30 Case Name Cause No. “Offender Registration” Attachment : sex offense, or kidnapping offense involving a minor as defined in RCW 9A.44.128. (If r e q uir e d , a tta ch t o S ta te m en t o f D efe n dan t o n P le a o f G uilty .)1 . G en era l A pplic ab ilit y a n d R eq uir e m en ts : B ecau se t h is c rim e i n volv es a s e x o ffe n se , o r a kid nap p in g o ffe n se i n volv in g a m in or a s d efin ed i n R CW 9 A .4 4.1 28 , I w ill b e r e q uir e d t o r e g is te r.If I a m a r e sid en t o f W ash in gto n, I m ust r e g is te r w ith t h e s h erif f o f t h e c o unty o f t h e s ta te o f W ash in gto n where I r e sid e. I m ust r e g is te r w ith in t h re e b usin ess d ay s o f b ein g s e n te n ced u nle ss I a m i n c u sto dy, i n wh ic h c a se I m ust r e g is te r a t t h e t im e o f m y r e le ase w ith t h e p ers o n d esig nate d b y t h e a g en cy t h at h as ju ris d ic tio n o ver m e. I m ust a ls o r e g is te r w ith in t h re e b usin ess d ay s o f m y r e le ase w ith t h e s h erif f o f t h e co u nty o f t h e s ta te o f W ash in gto n w here I w ill b e r e sid in g. W hile i n c u sto dy , i f I a m a p pro ved f o r p artia l c o nfin em en t, I m ust r e g is te r w hen I t r a n sfe r t o p artia l co n fin em en t w ith t h e p ers o n d esig nate d b y t h e a g en cy t h at h as j u ris d ic tio n o ver m e. I m ust a ls o r e g is te r wit h in t h re e b usin ess d ay s f ro m t h e e n d o f p artia l c o nfin em en t o r r e le ase f ro m c o nfin em en t w ith t h e s h erif f of t h e c o unty w here I r e sid e. I f I a m n o t a r e sid en t o f W ash in gto n , b ut I a m a s tu den t i n W ash in gto n o r I a m e m plo yed i n W ash in gto n o r I ca rry o n a v ocatio n i n W ash in gto n, I m ust r e g is te r w ith t h e s h erif f o f t h e c o unty o f m y s c h ool, p la ce o f em plo y m en t, o r v ocatio n. I m ust r e g is te r w ith in t h re e b usin ess d ay s o f b ein g s e n te n ced u nle ss I a m i n cu sto dy , i n w hic h c ase I m ust r e g is te r a t t h e t im e o f m y r e le ase w ith t h e p ers o n d esig nate d b y t h e a g en cy that h as j u ris d ic tio n o ver m e. I m ust a ls o r e g is te r w ith in t h re e b usin ess d ay s o f m y r e le ase w ith t h e s h erif f of t h e c o unty o f m y s c h ool, w here I a m e m plo yed , o r w here I c arry o n a v ocatio n.2 . O ffe n ders W ho A re N ew R esid en ts , T em pora ry R esid en ts , o r R etu rn in g W ash in gto n Res id en ts : I f I m ove t o W ash in gto n o r i f I l e av e t h is s ta te f o llo w in g m y s e n te n cin g o r r e le ase f ro m custo dy b ut l a te r m ove b ack t o W ash in gto n, I m ust r e g is te r w ith in t h re e b usin ess d ay s a fte r m ovin g t o t h is sta te . I f I l e av e t h is s ta te f o llo w in g m y s e n te n cin g o r r e le ase f ro m c u sto dy, b ut l a te r w hile n ot a r e sid en t o f Wa sh in gto n I b eco m e e m plo yed i n W ash in gto n, c arry o n a v ocatio n i n W ash in gto n, o r a tte n d s c h ool i n Wash in gto n, I m ust r e g is te r w ith in t h re e b usin ess d ay s a fte r a tte n din g s c h ool i n t h is s ta te o r b eco m in g em plo y ed o r c a rry in g o ut a v ocatio n i n t h is s ta te . If I am visiting and intend to reside or be present 10 or more days in Washington, then I must register the location where I plan to stay or my temporary address with the sheriff of each county where I will be staying within 3 business days of my arrival.3. C han ge o f R esid en ce W it h in S ta te : I f I c h an ge m y r e sid en ce w ith in a c o unty , I m ust p ro vid e, b y certif ie d m ail, w ith r e tu rn r e ceip t r e q ueste d o r i n p ers o n, s ig n ed w ritte n n otic e o f m y c h an ge o f r e sid en ce t o th e s h erif f w ith in t h re e b usin ess d ay s o f m ovin g. I f I c h an ge m y r e sid en ce t o a n ew c o unty w ith in t h is s ta te , I m ust r e g is te r w ith t h e s h erif f o f t h e n ew c o unty w ith in t h re e b usin ess d ay s o f m ovin g. A ls o w ith in t h re e bu sin ess d ay s, I m ust p ro vid e, b y c ertif ie d m ail, w ith r e tu rn r e ceip t r e q ueste d o r i n p ers o n, s ig ned w ritte n notic e o f m y c h an ge o f a d dre ss t o t h e s h erif f o f t h e c o unty w here I l a st r e g is te re d . 4. Leaving the State or Moving to Another State: If I move to another state, or if I work, carry on a vocation, or attend school in another state, I 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 I move out of state, I 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 I last registered in Washington State.5. Travel Outside the United States: If I intend to travel outside the United States, I must provide signed, written notice of the details of my plan to travel out of the country to the sheriff of the county where I am registered. Notice must be provided at least 21 days before I travel. Notice may be provided to the sheriff by certified mail, with return receipt requested, or in person. Sta te m ent o n P le a o f G uilt y ( “O ffe nder R eg.” A tta ch m ent) - Page 2 of 2CrR 4.2(g) (1 2/2 015) R CW 1 0.0 1.2 00, 9 A .4 4.1 30 If I cancel or postpone this travel, I must notify the sheriff within three days of canceling or postponing my travel or on the departure date I provide in my notice, whichever is earlier. If I travel routinely across international borders for work, or if I must travel unexpectedly due to a family or work emergency, I must personally notify the sheriff at least 24 hours before I travel. I must explain to the sheriff in writing why it is impractical for me 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) : I must give notice to the sh erif f o f t h e c o unty w here I a m reg is te re d w ith in t h re e b usin ess d ay s:i) b efo re a rriv in g a t a s c h ool o r i n stitu tio n o f h ig her e d ucatio n t o a tte n d c la sse s;ii) b efo re s ta rtin g w ork a t a n i n stitu tio n o f h ig her e d ucatio n; o riii) A fte r a n y t e rm in atio n o f e n ro llm en t o r e m plo ym en t a t a s c h ool o r i n stitu tio n o f h ig her e d ucatio n.7 . R eg is tr a tio n b y a P ers o n W ho D oes N ot H ave a F ix ed R esid en ce : E ven i f I d o n o t h av e a fix ed r e sid en ce, I a m r e q uir e d t o r e g is te r. R eg is tr a ti o n m ust o ccu r w ith in t h re e b usin ess d ay s o f r e le ase i n th e c o unty w here I a m b ein g s u perv is e d i f I d o n ot h av e a r e sid en ce a t t h e t i m e o f m y r e le ase f ro m c u sto dy . Wi t h in t h re e b usin ess d ay s a fte r l o sin g m y f ix ed r e sid en ce, I m ust s e n d s ig ned w ritte n n oti c e t o t h e s h erif f of t h e c o unty w here I l a st r e g is te re d . I f I e n te r a d if fe re n t c o u nty a n d s ta y t h ere f o r m ore t h an 2 4 h ours , I wil l b e r e q uir e d t o r e g is te r w ith t h e s h erif f o f t h e n ew c o unty n ot m ore t h an t h re e b usin ess d ay s a fte r en te rin g t h e n ew c o unty . I m ust a ls o r e p ort i n p ers o n t o t h e s h erif f o f t h e c o unty w here I a m r e g is te re d o n a we e k ly b asis . T he w eek ly r e p ort w ill b e o n a d ay s p ecif ie d b y t h e c o unty s h erif f’s o ffic e, a n d s h all o ccu r du rin g n o rm al b usin ess h ours . I m ust k eep a n a ccu ra te a cco untin g o f w here I s ta y d urin g t h e w eek a n d pro vid e i t t o t h e c o unty s h erif f u pon r e q uest. T he l a ck o f a f ix ed r e sid en ce i s a f a c to r t h at m ay b e co n sid ere d i n d ete rm in in g a s e x o ffe n der’s r is k l e v el a n d s h all m ak e m e s u bje c t t o d is c lo su re t o t h e p ublic a t la rg e p u rs u an t t o R CW 4 .2 4.5 50.8 . A pplic atio n f o r a N am e C han ge: I f I a p ply f o r a n am e c h an ge, I m ust s u bm it a c o py o f t h e ap p lic ati o n t o t h e c o unty s h erif f o f t h e c o unty o f m y r e sid en ce a n d t o t h e s ta te p atr o l n ot f e w er t h an f iv e day s b efo re t h e e n tr y o f a n o rd er g ra n tin g t h e n am e c h an ge. I f I r e ceiv e a n o rd er c h an gin g m y n am e, I m ust su b m it a c o py o f t h e o rd er t o t h e c o unty s h erif f o f t h e c o unty o f m y r e sid en ce a n d t o t h e s ta te p atr o l w ith in th re e b u sin ess d ay s o f t h e e n tr y o f t h e o rd er. R CW 9 A .4 4.1 30(7 ).D ate : Defendant’s signature