APPLICANT DISCLOSURE PURSUANT TO RCW 43.43.834

CHILD AND ADULT ABUSE INFORMATION ACT

Answer YES or NO to each listed item. If the answer is YES to any item, explain in the area provided, indicating the charge or finding, the date, and the court(s) involved.

PLEASE FILL OUT BOTH SIDES OF THE FORM

1. Have you ever been convicted of any crimes against children or other persons, as follows: aggravated murder; first or second degree murder; first or second degree kidnapping; first, second, or third degree assault, first, second, or third degree rape; first, second, or third degree rape of a child; first or second degree robbery; first degree arson; first degree burglary; first or second degree manslaughter; first or second degree extortion; indecent liberties; incest, vehicular homicide; first degree promoting prostitution; communication with a minor; unlawful imprisonment; simple assault; sexual exploitation of minors; first or second degree criminal mistreatment; child abuse or neglect as defined in RCW 26.44.020; first or second degree custodial interference; malicious harassment; first, second, or third degree child molestation; first or second degree sexual misconduct with a minor; patronizing a juvenile prostitute; child abandonment; promoting pornography; selling or distributing erotic material to a minor; custodial assault; violation of child abuse restraining order; child buying or selling; prostitution?

ANSWER IF YES, EXPLAIN BELOW:

2. Have you ever been convicted of crimes relating to the financial exploitation if the victim was a vulnerable adult, as follows: first, second, or third degree extortion; first, second, or third degree theft; first or second degree robbery; forgery?

ANSWER IF YES, EXPLAIN BELOW:

3. Have you ever been found in any dependency action under RCW 13.34.030 (2) (b) to have sexually assaulted or exploited any minor or to have physically abused any minor?

ANSWER IF YES, EXPLAIN BELOW:

4. Have you ever been found in any domestic relations proceeding under Title 26 RCW to have sexually abused or exploited any minor or to have physically abused any minor?

ANSWER IF YES, EXPLAIN BELOW:

5. Have you ever been found in any disciplinary board final decision to have sexually or physically abused or exploited any minor or developmentally disabled person or to have abused or financially exploited any vulnerable adult?

ANSWER IF YES, EXPLAIN BELOW:

6. Have you ever been found in any protection proceeding under chapter 74.34 RCW, to have abused or financially exploited a vulnerable adult?

ANSWER IF YES, EXPLAIN BELOW:

Pursuant to RCW 9A.72.085, I certify under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.

SIGNATURE DATE