Felony Judgment and Sentence (FJS) (Prison)(Nonsex Offender) Page 1 of 11
(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 -- Prison
(FJS)
[ ] Clerk’s Action Required, para 2.1, 4.1, 4.3 , 4.8
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)
prosec uting 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 RC W 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 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) .
[ ] The defendant used a firearm in the commission of the offense in Count ______________. RC W 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.
Felony Judgment and Sentence (FJS) (Prison)(Nonsex Offender) Page 2 of 11
(RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9))
[ ] Count ______________________, is aggravated murder in the firs t degree committed while the defendant was
[ ] under 16 years of age [ ] 16 or 17 years of age when the offense was committed.
[ ] Count ______________________, was committed while the defendant was under 18 years of age and the time
of confinement i s over 20 years.
[ ] Count _______________________, Violation of the Uniform Controlled Substances Act (VUCSA) , 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 fee t 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 comm itted 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.
[ ] 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 defendant was a criminal
street gang member or associate when the defendant committed the crime. RCW 9.94A.702, 9.94A.829.
[ ] The defendant committed [ ] vehicular homicide [ ] vehicu lar assault proximately caused by driving a
vehicle while under the influence of intoxicating liquor or drug or by operating a vehicle in a reckless manner.
The offense is, therefore, deemed a violent offense. RCW 9.94A.030.
GY [ ] In Count _______, th e defendant had (number of) ______ passenger(s) under the age of 16 in the vehicle.
RCW 9.94A.533.
[ ] Count __________ involves attempting to elude a police vehicle and during the commission of the crime the
defendant endangered one or more persons oth er than the defendant or the pursuing law enforcement officer.
RCW 9.94A.834.
[ ] In Count ______________ the defendant has been convicted of assaulting a law enforcement officer or other
employee of a law enforcement agency who was performing his or he r official duties at the time of the assault,
as provided under RCW 9A.36.031, and the defendant intentionally committed the assault with what appeared 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 7 1.24.025, and
that this condition is likely to have influenced the offense. RCW 9.94B.080
[ ] In Count ______, assault in the 1 st degree (RCW 9A.36.011) or assault of a child in the 1 st degree (RCW
9A.36.120), the offender used force or means likely to result in death or intended to kill the victim and shall be
subject to a mandatory minimum term of 5 years (RCW 9.94A.540).
[ ] 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 wa s pled and proved.
[ ] Additional current convictions listed under different cause numbers used in calculating the offender score are
attached in Appendix 2.1b.
Felony Judgment and Sentence (FJS) (Prison)(Nonsex Offender) Page 3 of 11
(RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9))
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
4
5
* DV: Domestic Violence was pled and proved.
[ ] Additional criminal history is attached in Appendix 2.2.
[ ] The defendant commit ted 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) .
[ ] The prior convictions listed as number(s) ____________, above, or in appendix 2.2, are not counted as points
but as enhancements pursuant to RCW 46.61.520.
2.3 Sentencing Data :
Count
No.
Offender
Score
Serious -
ness
Level
Stan dard
Range (not including enhancements)
Plus
Enhancements*
Total Standard
Range (including enhancements)
Maximum
Term
* (F) Firearm, (D) Other deadly weapons, (V) VUCSA in a protected zone, (RPh) Robbery of a pharmacy,
(VH ) Veh. Hom, see RCW 9.94A.533(7), (JP) Juvenile present, (CSG) Criminal street gang involving minor,
(AE) Endangerment while attempting to elude, (ALF) Assault law enforcement with firearm, RCW
9.94A.533(12), (P16) Passenger(s) under age 16.
[ ] Additio nal 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 [ ] Exceptional Sentence . 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) _________ ______.
Felony Judgment and Sentence (FJS) (Prison)(Nonsex Offender) Page 4 of 11
(RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9))
[ ] The defendant and state stipulate 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/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 specific findings:
[ ] 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 (RC W
9.94A.753):
________________________________ ________________________________ ________________
[ ] The defendant has the present means to pay costs of incarceration. RCW 9.94A.760.
[ ] (Name of agency) ___________________________ ‘s costs for its emergency response are
reasonble. RCW 38.52.430 (effective August 1, 2012).
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 determin ation:
[ ] 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 endang er 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 t he 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 Cou nts in
the charging document.
IV. Sentence and Order
It is ordered :
4.1 Confinement . The court sentences the defendant to total confinement as follows:
(a) Confinement . RCW 9.94A.589. 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) :
months on Count months on Count
months on Count months on Count
months on Count months on Count
Felony Judgment and Sentence (FJS) (Prison)(Nonsex Offender) Page 5 of 11
(RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9))
[ ] The confinement time on Count(s)___________ contain(s) a mandatory minimum term of __________.
[ ] The confinement time on Count __________________________ includes _____________ months as
enhancement f or [ ] firearm [ ] deadly weapon [ ] VUCSA in a protected zone
[ ] manufacture of methamphetamine with juvenile present [ ] impaired driving.
Actual number of months of total confinement ordered is: ______ _______________________________
(b) Confi nement . RCW 10.95.030 (Aggravated murder and under age 18.) The court orders the following:
Count minimum term: maximum term: Life
Count minimum term: maximum term: Life
All counts shall be served concurrently, except for the portion of those c ounts for which there is an
enhancement as set forth above at Section 2.3, and except for the following counts which shall be served
consecutively: ________________________________ ________________________________ _________
This sentence shall run consecutively with the sentence in the following cause number(s) (see RCW
9.94A .589(3) ): ________________________________ ________________________________ _________
Confinement shall commence immediately unless otherwise set forth here: __________________________
________________________________ ________________________________ _____________________
(c) 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.
(d) [ ] Work Ethic Program . RCW 9.94A.690, RCW 72.09.410. The court finds that the defendant is
eligible and is likely to qualify for work ethic program. The court recommends that the defendant serv e the
sentence at a work ethic program. Upon completion of work ethic program, the defendant shall be released
on community custody for any remaining time of total confinement, subject to the conditions in Section 4.2.
Violation of the conditions of commu nity custody may result in a return to total confinement for the balance
of the defendant’s remaining time of confinement.
4.2 Community Custody . (To determine which offenses are eligible for or required for community custody
see RCW 9.94A.701, RCW 10. 95.030(3))
(A) The defendant shall be on community custody for:
Count(s) _____________ 36 months for Serious Violent Offenses
Count(s) _____________ 18 months for Violent Offenses
Count(s) _____________ 12 months (for crimes against a person, drug offe nses, or offenses involving the
unlawful possession of a firearm by a street gang member or
associate)
Note: combined term of confinement and community custody for any particular offense cannot exceed the
statutory maximum. RCW 9.94A.701.
(B) While on com munity custody, the defendant shall: (1) report to and be available for contact with the
assigned community corrections officer as directed; (2) work at DOC -approved education, employment and/or
community restitution (service); (3) notify DOC of any chang e in defendant’s address or employment; (4) not
consume controlled substances except pursuant to lawfully issued prescriptions; (5) not unlawfully possess
controlled substances while on community custody; (6) not own, use, or possess firearms or ammunition ;
(7) pay supervision fees as determined by DOC; (8) perform affirmative acts as required by DOC to confirm
compliance with the orders of the court; and (9) abide by any additional conditions imposed by DOC under
RCW 9.94A.704 and .706. The defendant’s r esidence location and living arrangements are subject to the prior
approval of DOC while on community custody.
The court orders that during the period of supervision the defendant shall:
[ ] not possess or consume alcohol.
[ ] not possess or consume controlled substances, including marijuana, without a valid prescription.
Felony Judgment and Sentence (FJS) (Prison)(Nonsex Offender) Page 6 of 11
(RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9))
[ ] have no contact with: ___________________________________________.
[ ] remain [ ] within [ ] outside of a specified geographical boundary, to wit:
___________________ _______________________________ _______________________________
[ ] not serve in any paid or volunteer capacity where he or she has control or supervision of minors under
13 years of age.
[ ] participate in the following crime -related treatment or co unseling services:
__________________________________________________ _______________________________
[ ] undergo an evaluation for treatment for [ ] domestic violence [ ] substance use disorder [ ] mental health
[ ] anger management, and fully c omply with all recommended treatment.
[ ] comply with the following crime -related prohibitions: ________________________________ _________
________________________________ ________________________________ ____________________
________________________________ ________________________________ ____________________
[ ] Other conditions:
________________________________ ________________________________ ____________________
________________________________ ________________________________ ____________________
________________________________ ________________________________ ____________________
________________________________ ________________________________ ____________________
Court Ordered Treatment: If any court orders mental health or substance use disorder treatment, the defendant
must not ify DOC and the defendant must release treatment information to DOC for the duration of
incarceration and supervision. RCW 9.94A.562.
(C) If the defendant committed the above crime(s) while under age 18 and is sentenced to more than 20 years
of confineme nt:
(i) As long as the defendant’s conviction is not for aggravated first degree murder or certain sex
crimes, and the defendant has not been convicted of any crime committed after he or she turned 18
or committed a disqualifying serious infraction as defined by DOC in the 12 months before the
petition is filed, the defendant may petition the Indeterminate Sentence Review Board (Board) for
early release after the defendant has served 20 years.
(ii) If the defendant is released early because the petition was gran ted or by other action of the Sentence
Review Board, the defendant will be subject to community custody under the supervision of the DOC
for a period of time determined by the Board, up to the length of the court -imposed term of
incarceration. The defenda nt will be required to comply with any conditions imposed by the Board.
(iii) If the defendant violates the conditions of community custody, the Board may return the defendant to
confinement for up to the remainder of the court -imposed term of incarceration .
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
Felony Judgment and Sentence (FJS) (Prison)(Nonsex Offender) Page 7 of 11
(RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9))
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 additional
MTH 3337 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
$____________ DUI fines, fees and assessments
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:
DEF 3506 $ Emergency response costs ($1000 maximum, $2,500 max. effective Aug. 1,
2012.) RCW 38.52.430
Agency:
$ 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.75 3. 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):_____________
[ ] Restitution Schedule attached.
[ ] Restitu tion 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 DOC or the clerk of the court, commencing immediately, unless the court specifically set s
forth the rate here: Not less than $________ per month commencing_____________________. RCW
9.94A.760. (Restitution payments must begin immediately. RCW 9.4A.750(1).)
Felony Judgment and Sentence (FJS) (Prison)(Nonsex Offender) Page 8 of 11
(RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9))
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 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 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 Washington State Patrol c rime 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 .
[ ] 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 c oming 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 se ntence).
[ ] A separate Domestic Violence No -Contact Order, Antiharassment No -Contact Order, or Stalking No -
Contact Order is filed concurrent with this Judgment and Sentence.
4.6 Other :
4.7 Off -Limits Order . (Known drug trafficker). RCW 10.66.0 20. The following areas are off limits to the
defendant while under the supervision of the county jail or Department of Corrections: _________________
________________________________ ________________________________ ______________________
4.8 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, moti on 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 for in RCW 10.73.100.
RCW 10.73.090.
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(RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9))
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.505(5). The clerk of the court has
authority to collect unpaid legal financial obligat ions 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 p ayroll
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 term of total confinement and you are subject to a violation hearing
and DOC finds tha t 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
in Washington State where you live, and by a federal court if required. You must immediately surrender any
concealed pistol license. (The cle rk 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 R egistration . 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
5.7 [ ] Department of Licensing Notice: The court finds t hat 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, Vehicular Assault, or Vehicular
Homicide (ACR information) (Check all that apply) :
[ ] Within two hours after driving or being in physical control of a vehicle, the defendant had an alcohol
concentration 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 [ ] Depart ment 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 violat ion
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 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.
Felony Judgment and Sentence (FJS) (Prison)(Nonsex Offender) Page 10 of 11
(RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9))
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 the presence of the defendant this date :______________________________
_______________________________________________
Judge /Print Name:
_____________________________ ____________________________ _____________________________
Deputy Prosecuting Attorney Attorney for Defendant De fendant
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 cancelled.
My r ight 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 pr ovisional 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 fel ony 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 sentence review bo ard, 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 cl ass C felony, RCW 29A.84.660. Registering to vote before the right is restored is a class C felony, RCW
29A.84.140.
De fendant’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 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) (Prison)(Nonsex Offender) Page 11 of 11
(RCW 9.94A.500, .505)(WPF CR 84.0400 ( 07/201 9))
VI. Identification of the Defend ant
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 Alask a 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 t aken simultaneously
Left
Thumb
Right
Thumb
Right four fingers taken simultaneously
