Felony Judgment and Sentence (FJS) Page 1 of 11(First-Time Offender)(RCW 9.94A.500, .505)(WPF CR 84.0400 (06/2018))Superior Court of WashingtonCounty ofState of Washington , Plaintiff,vs.______________________________________,Defendant. DOBPCN:SID:No.Felony Judgment and Sentence --First-Time Offender (FJS) Clerk’s Action Required, 2.1, 3.2, 4.1, 4.3, 4.7,
5.2, 5.3, 5.5, 5.7, and 5.8 Defendant Used Motor Vehicle Juvenile Decline Mandatory Discretionary I. Hearing 1.1 The court conducted a sentencing hearing this date; the defendant, the defendant's lawyer, and 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 RCWClassDate of
(w/subsection)CrimeClass: 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) was pled and proved. GV For the crime(s) charged in Count ____________, domestic violence (other) was pled and proved.
RCW 10.99.020. The defendant has a chemical dependency that has contributed to the offense(s). RCW 9.94A.607.
Felony Judgment and Sentence (FJS) Page 2 of 11(First-Time Offender)(RCW 9.94A.500, .505)(WPF CR 84.0400 (06/2018)) 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 felony in the commission of which the defendant used a motor vehicle. RCW46.20.285. Counts __________________ encompass the same criminal conduct and count as one crime in determining the
offender score (RCW 9.94A.589). Other current convictions listed under different cause numbers used in calculating the offender score are
(list offense and cause number): Crime Cause Number Court (county & state) DV*Yes1.2.* DV: Domestic Violence was pled and proved. Additional current convictions listed under different cause numbers used in calculating the offender score are
attached in Appendix 2.1b. 2.2 Criminal History (RCW 9.94A.525): Crime Date of
CrimeDate of
SentenceSentencing Court(County & State)A or JAdult, Juv.Typeof CrimeDV*Yes123* DV: Domestic Violence was pled and proved.2.3Sentencing Data:CountNo.OffenderScoreSerious- ness LevelStandardRange (not
including enhancements)Plus Enhancements*Total StandardRange (including
enhancements)Maximum Term N/AN/AN/A Additional current offense sentencing data is attached in Appendix 2.3. 2.4First-Time Offender Waiver. The court finds that the defendant qualifies for waiver of a standard range
sentence.2.5Legal 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:
Felony Judgment and Sentence (FJS) Page 3 of 11(First-Time Offender)(RCW 9.94A.500, .505)(WPF CR 84.0400 (06/2018)) receives public assistance is involuntarily committed to a public mental health facility receives
an annual income, after taxes, of 125 percent or less of the current federal poverty level.The defendant is not indigent as definied in RCW 10.101.010(3)(a)-(c).The following extraordinary circumstances exist that make restitution inappropriate (RCW
9.94A.753): _________________________________________________________________________________ . The defendant has the present means to pay the costs of incarceration. RCW 9.94A.760. 2.6 Felony Firearm Offender Registration. The defendant committed a felony firearm offense as
defined in RCW 9.41.010, and: The defendant should register as a felony firearm offender. The court considered the following factors
in making this determination: the defendant’s criminal history. whether the defendant has previously been found not guilty by reason of insanity of any offense in
this state or 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 3.1The 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 First-Time Offender Waiver of Standard Sentence. RCW 9.94A.030, RCW 9.94A.650. The
defendant is a first-time offender. The court waives imposition of a sentence within the standard sentence
range and imposes the following sentence: (a)Confinement. The court sentences the defendant to the following term of total confinement in the
custody of the county jail: __________________________________days total confinement (up to 90 days). RCW 9.94A.650.Other:_____________________________________________________________________________ .Confinement shall commence immediately unless otherwise set forth here:___________________________________________________________________________________________________________ . Credit for Time Served: The defendant shall receive credit for eligible time served prior to sentencing
if that confinement was solely under this cause number. RCW 9.94A.505. The jail shall compute time
served. Partial Confinement. The defendant may serve the sentence, if eligible and approved, in partial confinement in the following programs, subject to the following conditions: ________________________ _________________________________________________________________________________ . work crew RCW 9.94A.725 home detention RCW 9.94A.731, .190 work release RCW 9.94A.731 electronic monitoring RCW 9.94A.030 Alternative Conversion. RCW 9.94A.680. _____________ days of total confinement ordered
above are hereby converted to ___________ hours of community restitution (service) (8 hours = 1 day,
nonviolent offenders only, 30 days maximum) under the supervision of the Department of Corrections
(DOC) to be completed: on a schedule established by the defendant's community corrections officer.
Felony Judgment and Sentence (FJS) Page 4 of 11(First-Time Offender)(RCW 9.94A.500, .505)(WPF CR 84.0400 (06/2018)) as follows:________________________________________________________________ . Conversion of Jail Confinement (Nonviolent and Nonsex Offenses) . RCW 9.94A.680(3). The
county jail is authorized to convert jail confinement to an available county supervised community option, to
reduce the time spent in the community option by earned release credit consistent with local correctional
facility standards, and may require the offender to perform affirmative conduct pursuant to
RCW 9.94A.607. The defendant shall receive credit for time served in an available county supervised community
option prior to sentencing. The jail shall compute time served. Alternatives to total confinement were not used because of: ____________________________ criminal history failure to appear (finding required for nonviolent offenders only) RCW
9.94A.680. (b)Community Restitution (Service). RCW 9.94A.650. The defendant shall perform ___________
hours of community restitution (service) as approved by the defendant's community corrections officer to
be completed: on a schedule established by the defendant's community corrections officer. as follows:______________________________________________________________________ . This community restitution is in addition to the ordered total confinement.
4.2Community Custody. RCW 9.94A.650. The defendant shall serve _______________ months in
community custody under the supervision of DOC (up to12 months if treatment is ordered and up to 6 months
if treatment is not ordered).The defendant shall report to the DOC not later than 72 hours after 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 obey all laws, perform affirmative acts as required by DOC to confirm compliance with the orders of the
court. The defendant shall comply with any other conditions of community custody stated in this Judgment and
Sentence or imposed by DOC under RCW 9.94A.704 and .706 during community custody. While under
supervision, the defendant shall not own, use, or possess firearms or ammunition. The court orders that during
the period of supervision the defendant shall: pay all court-ordered legal financial obligations. notify the community corrections officer in
advance of any change in defendant’s address or
employment. report as directed to a community corrections
officer. devote time to specific employment or
occupation. not possess or consume alcohol. not possess or consume controlled substances,
including marijuana, without a valid prescription. undergo available treatment for a period not to
exceed one year. remain within prescribed geographical boundaries. obtain a mental health evaluation and comply with
recommended treatment. obtain a substance use disorder evaluation and
comply with recommended treatment. The conditions of community custody shall begin immediately unless otherwise set forth here:________________________________________________________________________________________ .Court-Ordered Treatment: If any court orders mental health or substance use disorder treatment, the defendant
must notify DOC and the defendant must release treatment information to DOC for the duration of
incarceration and supervision. RCW 9.94A.562.
Felony Judgment and Sentence (FJS) Page 5 of 11(First-Time Offender)(RCW 9.94A.500, .505)(WPF CR 84.0400 (06/2018))4.3Legal Financial Obligations: The defendant shall pay to the clerk of this court:JASS/Odyssey CODEPCV 3101 $ 500Victim assessment RCW 7.68.035PDV 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 FRCWitness costs $ WFRSheriff service fees $ SFR/SFS/SFW/WRFJury demand fee $ JFRExtradition costs $ EXTOther $ PUB 3225$ Fees for court appointed attorney RCW 9.94A.760WFR 3231$ Court appointed defense expert and other defense costs RCW 9.94A.760FCM 3303 $ Fine RCW 9A.20.021; VUCSA chapter 69.50 RCW, VUCSA MTH 3337 additional fine deferred due to indigency RCW 69.50.430CDF 3302 $ Drug enforcement fund of ____________________RCW 9.94A.760LDI 3308/FCD 3363NTF 3338/SAD 3365/SDI 3307CLF 3212$ Crime lab fee suspended due to indigency RCW 43.43.690 $ 100DNA c o lle ctio n f e e suspended. DNA previously collected RCW 4 3.4 3.7 541 F PV 3 33 5 $ Specia liz ed f o re st p ro ducts RCW 7 6.4 8.1 71 $ 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_____________________________________________________________________________________
Felony Judgment and Sentence (FJS) Page 6 of 11(First-Time Offender)(RCW 9.94A.500, .505)(WPF CR 84.0400 (06/2018)) ______________________________________________________________________________________ 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. 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 9.94A.750 and RCW 9.94A.753.) 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. 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. 4.4DNA Testing. The defendant shall have a biological sample collected for purposes of DNA identification
analysis and the defendant shall fully cooperate in the testing. The appropriate agency shall be responsible for
obtaining the sample prior to the defendant's release from confinement. This paragraph does not apply if it is
established that the Washington State Patrol crime laboratory already has a sample from the defendant for a
qualifying offense. RCW 43.43.754. HIV Testing . The defendant shall submit to HIV testing. RCW 70.24.340. 4.5No Contact: The defendant shall not have contact with ________________________________________________
__________________________________________________________ (name/s) including, but not limited
to, personal, verbal, telephonic, written, or contact through a third party until _________________ (which
does not exceed the maximum statutory sentence). The defendant is excluded or prohibited from coming within ______________________ (distance) of: _______________________________________________(name of protected person/s)’s home/
residence
work place school (other location/s) ______________________________________ _________________________________________________________________________________, or other location ___________________________________________________________________, until _______________________ (which does not exceed the maximum statutory sentence). A separate Domestic Violence No-Contact Order, Antiharassment No-Contact Order, Stalking No-Contact
Order, or Sexual Assault Protection Order is filed concurrent with this Judgment and Sentence. 4.6Other : 4.7Exoneration: The Court hereby exonerates any bail, bond, and/or personal recognizance conditions. V. Notices and Signatures
Felony Judgment and Sentence (FJS) Page 7 of 11(First-Time Offender)(RCW 9.94A.500, .505)(WPF CR 84.0400 (06/2018))5.1Collateral 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 final judgment in this matter, except as provided for in RCW 10.73.100.
RCW 10.73.090.5.2Length 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, 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 and RCW 9.94A.753(4).5.3Notice 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.7606.5.4Community Custody Violation.If you are subject to a violation hearing and DOC finds that you committed the violation, you may receive a
sanction of up to 30 days of confinement. RCW 9.94A.633(1).5.5a Firearms. You may not own, use or possess any firearm, and under federal law any firearm or
ammunition, unless your right to do so is restored by the court in which you are convicted or 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 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. T he d efe n dan t i s r e q uir e d t o r e g is te r a s a f e lo ny f ir e arm offe n der. T he s p ecif ic r e g is tr a tio n r e q uir e m en ts a re i n t h e “ F elo ny F ir e arm O ffe n der R eg is tr a tio n”
atta ch m en t. Delete or cross off if not applicable:5.6 Offender Registration. (Unlawful Imprisonment Involving a Minor) RCW 9A.44.128,
9A.44.130, 10.01.200. 1. G en era l A pp lic ab ilit y a n d R eq uir e m en ts : Because this crime involves a sex offense or kidnapping
offense involving a minor as defined in RCW 9A.44.128, you are required to register. If you are a resident of Washington, you must register with the sheriff of the county of the state of Washington where you reside. You must register within three business days of being sentenced unless
you are in custody, in which case you must register at the time of your release with the person designated
by the agency that has jurisdiction over you. You must also register within three business days of your
release with the sheriff of the county of the state of Washington where you will be residing.While i n c u sto dy, i f y ou a re a p pro ved f o r p artia l c o nfin em en t, y ou m ust r e g is te r w hen y ou t r a n sfe r t o p artia l
co nfin 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 y ou. Y ou m ust a ls o r e g is te r
with 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 y ou r e sid e. If y o u a re n ot a r e sid en t o f W ash in gto n b ut y ou a re a s tu den t i n W ash in gto n o r y ou a re e m plo yed i n
Wash in gto n o r y ou c arry o n a v ocatio n i n W ash in gto n, y ou 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
yo ur s c h ool, p la ce o f e m plo ym en t, o r v ocatio n. Y ou 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
sen te n ced u n le ss y ou a re i n c u sto dy, i n w hic h c ase y ou m ust r e g is te r a t t h e t im e o f y our r e le ase w ith t h e
Felony Judgment and Sentence (FJS) Page 8 of 11(First-Time Offender)(RCW 9.94A.500, .505)(WPF CR 84.0400 (06/2018))pers 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 y ou. Y ou m ust a ls o r e g is te r w ith in t h re e b usin ess
da y s o f y our r e le a se w ith t h e s h erif f o f t h e c o unty o f y our s c h ool, w here y ou a re e m plo yed , o r w here y ou
carry 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
Resid en ts : If you move to Washington or if you leave this state following your sentencing or release
from custody but later move back to Washington, you must register within three business days after
moving to this state. If y ou l e av e t h is s ta te f o llo w in g y our 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
no t a r e sid en t o f W ash in gto n y ou b eco m e e m plo yed i n W ash in g to n, c arry o n a v ocatio n i n W ash in gto n, o r
atte n d s c h ool i n W ash in gto n, y ou m ust r e g is te r w ith in t h re e b usin ess d ay s a fte r s ta rtin g s c h ool i n t h is s ta te o r
be co m in g e m plo yed o r c arry in g o ut a v ocatio n i n t h is s ta te . 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. C han ge o f R esid en ce W it h in S ta te : I f y ou c h an ge y our r e sid en ce w ith in a c o unty , y ou m ust p ro vid e,
by 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 n otic e o f y our c h an ge o f
re sid en ce t o t h 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 y ou c h an ge y our r e sid en ce t o a n ew c o unty
with in t h is s ta te , y ou 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.
Al s o w ith in t h re e b usin ess d ay s, y ou 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
pers o n, s ig ned w ritte n n otic e o f y our 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 y ou l a st r e g is te re d . 4. Leaving the State or Moving to Another State: If you move to another state, or if you work, carry
on a vocation, or attend school in another state you must register a new address, fingerprints, and
photograph with the new state within three business days after establishing residence, or after beginning
to work, carry on a vocation, or attend school in the new state. If you move out of the state, you must also
send written notice within three business days of moving to the new state or to a foreign country to the
county sheriff with whom you last registered in Washington State.5. Travel Outside the United States: If you intend to travel outside the United States, you must
provide signed written notice of the details of your plan to travel out of the country to the sheriff of the
county where you are registered. Notice must be provided at least 21 days before you travel. Notice may
be provided to the sheriff by certified mail, with return receipt requested, or in person. If you cancel or postpone this travel, you must notify the sheriff within three days of canceling or
postponing your travel or on the departure date you provide in your notice, whichever is earlier. If you travel routinely across international borders for work, or if you must travel unexpectedly due to a
family or work 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 sheriff of the co unty
where y ou a re r e g 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 y ou d o n ot h av e a
fix ed r e sid en ce, y ou a re r e q uir e d t o r e g is te r. R eg is tr a tio 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 y ou a re b ein g s u perv is e d i f y ou d o n ot h av e a r e sid en ce a t t h e t im e o f y our r e le ase f ro m
custo dy. W ith in t h re e b usin ess d ay s a fte r l o sin g y our f ix ed r e sid en ce, y ou m ust s e n d s ig ned w ritte n n otic e
to t h e s h erif f o f t h e c o unty w here y ou l a st r e g is te re d . I f y ou e n te r a d if fe re n t c o unty a n d s ta y t h ere f o r m ore
th an 2 4 h ours , y ou w ill b e r e q u ir 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
bu sin ess d ay s a fte r e n te rin g t h e n ew c o unty . Y ou m ust a ls o r e p ort w eek ly i n p ers o n t o t h e s h erif f o f t h e
co unty w here y ou a re r e g is te re d . T he w eek ly r e p ort s h all 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,
an d s h all o ccu r d urin g n orm al b usin ess h ours . Y ou m ust k eep a n a ccu ra te a cco untin g o f w here y ou s ta y
Felony Judgment and Sentence (FJS) Page 9 of 11(First-Time Offender)(RCW 9.94A.500, .505)(WPF CR 84.0400 (06/2018))durin g t h e w eek a n d p ro 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 cto r
th at m ay b e c o nsid ere d i n d ete rm in in g a n o ffe n der’s r is k l e v el a n d s h all m ak e t h e o ffe n der s u bje ct t o
dis c lo su re o f i n fo rm atio n t o t h e p ublic a t l a rg e p urs 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 y ou a p ply f o r a n am e c h an ge, y ou m ust s u bm it a c o py o f t h e
ap pli c atio n t o t h e c o unty s h erif f o f t h e c o unty o f y our 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 y ou r e ceiv e a n o rd er c h an gin g y our n am e,
yo u m ust s u 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 y our r e sid en ce a n d t o t h e s ta te
pa tr o l w ith in t h re e b usin 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 ).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. 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 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 the presence of the defendant this date: ______________________________. _______________________________________________Judge/ Print Name:
___________________________________________________________________________________
Deputy Prosecuting Attorney Attorney for Defendant Defendant WSBA No. WSBA No. Print Name: Print Name: Print Name:
Felony Judgment and Sentence (FJS) Page 10 of 11(First-Time Offender)(RCW 9.94A.500, .505)(WPF CR 84.0400 (06/2018))Voting Rights Statement: I acknowledge that I have lost my right to vote because of this felony conviction. If I
am registered to vote, my voter registration will be cancelled. My right to vote is provisionally restored as long as I am not under the authority of DOC (not serving a sentence of
confinement in the custody of DOC and not subject to community custody as defined in RCW 9.94A.030). I must re-
register before voting. The provisional right to vote may be revoked if I fail to comply with all the terms of my legal
financial obligations or an agreement for the payment of legal financial obligations.My right to vote may be permanently restored by one of the following for each felony conviction: a) a certificate of 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 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 class C felony, RCW
29A.84.140. Defendant’s signature: ______________________________________________I am a certified or registered interpreter, or the court has found me otherwise qualified to interpret, in the _________________________________ language, which the defendant understands. I interpreted this Judgment
and Sentence for the defendant into that language.I c ertif y u nder p en alty o f p erju ry u nder t h e l a w s o f t h e s ta te o f W ash in gto n t h at t h e f o re g oin g i s t r u e a n d c o rre ct.S ig ned a t ( c ity ) _ _ __________________, ( s ta te ) _ ______________, o n ( d ate ) _ _____________________._ __ ____ _______ ______________ ___________ _ ___________________________________________In te rp re te r Prin t N am e
Felony Judgment and Sentence (FJS) Page 11 of 11(First-Time Offender)(RCW 9.94A.500, .505)(WPF CR 84.0400 (06/2018)) 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/Pacific Islander Black/African-American Caucasian Hispanic Male Native American Other:________________________________ Non-Hispanic Female 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 simultaneouslyLeft
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ThumbRight four fingers taken simultaneously
