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FILED

C3J.' 130 F6 2 : 19

Sui' 1 ; wR C.,Qu'RT CLERKK ENT. W A

SUMMONS ISSUED

CHARGE COUNTY $200.00

SUPERIOR COURT OF WASHINGTON FOR KING COUNTY

THE STATE OF WASHINGTON, )

Plaintiff, )

v. ) No. 08- 1- 00262 -1 KNT

NAAMAN JAMAL WASHINGTON, ) INFORMATION

Defendant. )

I, Daniel T. Satterberg, Prosecuting Attorney for King County in the name and by theauthority of the State of Washington, do accuse NAAMAN JAMAL WASHINGTON of thecrime of Violation of the Uniform Controlled Substances Act, committed as follows:

That the defendant NAAMAN JAMAL WASHINGTON in King County, Washington, on or about November 23, 2007, unlawfully and feloniously did possess with intent tomanufacture or deliver MDMA (ecstasy), a controlled substance, and did know it was acontrolled substance;

Contrary to RCW 69.50.401( 1), ( 2)( c), and against the peace and dignity of the State ofWashington.

INFORMATION - 1

DANIEL T. SA'ITTERBERG

Prosecuting Attorney

By: C & DJFDeanna ennings Fuller, WSBA #7914

Senior Deputy Prosecuting Attorney

Daniel T. Satterberg, Prosecuting AttorneyNorm Maleng Regional Justice Center401 Fourth Avenue North

Kent, Washington 98032 -4429

Mt1G UR YiP Lr1nrt . w N

SUPERIOR COURT OF WASHINGTON FOR KING COUNTY

STATE OF WASHINGTON,

vs.

NAAMAN JAMAL WASHINGTON,

Plaintiff,

Defendant,

FIRST AMENDED INFORMATION

No. 08- 1- 002624 KNT

COUNT I

I, Dan Satterberg, Prosecuting Attorney for King County in the name and by theauthority of the State of Washington, do accuse NAAMAN JAMAL WASHINGTON, of thecrime of Conspiracy to Commit Violation of the Uniform Controlled Substance Act, committed as follows:

That the defendant NAAMAN JAMAL WASHINGTON„ in King County, Washington, on or about November 23, 2007, with the intent to commit the crime of Violation

of the Uniform Controlled Substances Act, Delivery of a Controlled Substance, to wit, MDMAecstacy), did feloniously agree with persons known and unknown, to engage in and cause the

performance of such conduct, and, one of the parties so agreeing did perform an overt actpursuant to such agreement.

Contrary to RCW 69. 50. 401 and 69. 50. 407, and against the peace and dignity of theState of Washington.

COUNT II

1ST AMENDED INFORMATION - 1 Norm Maleng, Prosecuting AttorneyRegional Justice Center

401 Fourth Avenue North

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And I, Dan Satterberg, Prosecuting Attorney for King County in. the name and by theauthority of the State of Washington, do accuse NAAMAN JAMAL WASHINGTON, of thecrime of Violation of the Uniform Controlled Substance Act, committed as follows:

That the defendant NAAMAN JAMAL WASHINGTON„ in King County, Washington, on or about November 23, 2007, unlawfully and feloniously did possessor

a controlled substance;

Contrary to RCW 69. 50. 4013, and against the peace and dignity of the State ofWashington.

4 ! = Il

1ST AMENDED INFORMATION - 2

Dane Satterberg, Prosecuting

By Tod Bergstrom, WSBA# 17973Senior Deputy Prosecuting Attorney

Norm Maleng, Prosecuting AttorneyRegional Justice Center

401 Fourth Avenue North

08 - 1- 00262 --1KNTCERTIFICATION FOR DETERMINATION OF PROBABLE CAUSE:

That Detective T. Rogers is a detective with the Federal Way Police Department and has reviewed theinvestigation conducted in Federal Way Police Department Case # 07 -17232

There is probable cause to believe that:

WASHINGTON, NAAMAN, JAMAL DOB /07 -26 -1977

committed the crime ofVUCSA Possession of Ecstasy with Intent to Deliver, VUCSA Possession ofPrescription Dug without a Prescription and Possession of Marijuana over 40 grams.

This belief is predicated on the following facts and circumstances:

On 11 -23 -2007 Officer Jimenez was on duty as a police officer in a fully marked patrol vehicle and policeuniform. Officer Jimenez observed vehicle Lic /016WCU traveling southbound on Pacific Highway withloud music coming from the vehicle, from more than 50 feet away. Officer Jimenez activated hisemergency lights and stopped the vehicle.

Upon contacting the driver and only occupant of the vehicle he was identified as WASHINGTON. ADOL check of WASHINGTON showed him to be DWLS 3rd and he was arrested. Search incident to

arrest a clear plastic bag containing 102 pills fell from WASHINGTON' S rights pants area to his rightfoot. WASHINGTON stated " Oh shit I forgot I had those ". Through Officer Jimenez' s training andexperience he recognized this to be ecstasy. Officer Jimenez read WASHINGTON his Miranda rightswhich he stated he understood. WASHINGTON denied owning the pills that had fallen out ofhis pantsbut did admit to ownership ofthe marijuana inside his car. Officer Jimenez located a single white oblongtablet in the driver' s door handle area of the vehicle. This tablet had the name WATSON /387 on one side

of it. Officer Jimenez began searching the vehicle and located several $20.00 bills on the driver floorboard ofthe vehicle directly under the middle console area of the front seat Officer Jimenez also located abaggie of suspected marijuana in the vehicle and at this time stopped his search and called for a narcotic K- 9 to continue this search.

Narcotics K -9 handler Officer Schwan and his K -9 " Caleb" arrived on scene to search the vehicle. The

narcotics K -9 gave a positive alert on the center console area of the vehicle. Officer Schwan searched the

center console and located a gallon zip -lock baggy ofsuspected marijuana. The money located inside thevehicle was placed into a paper bag along with two other empty paper bags and the narcotics K -9 " Caleb" conducted a sniff test on the bags, giving a positive hit to the bag containing the currency located inside thevehicle.

Officer Jimenez field- tested the suspected ecstasy and marijuana both ofwhich returned with positiveresults for there perspective drug. The marijuana had a weight of 45. 23 grams and there were 102 ecstasypills. Officer Jimenez used the Drug Bible and discovered the one prescription pill was Hydrocodone (aschedule III drug)

Uder penalty of perjury under the laws of the State of Washington, I certify that the foregoing is true andcorrect. Signed and dated by me this Wednesday, November 28, 2007 at Federal Way, King County, Washington.

Detective T. Rogers #77

Special Investigations Unit

Federal Way Police Department

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CAUSE NO. 08 -1- 00262 -1 KNT

PROSECUTING ATTORNEY CASE SUMMARY AND REQUEST FOR BAIL AND /OR

CONDITIONS OF RELEASE

The State incorporates by reference the Certification for Determination of ProbableCause written by Detective T. Rogers, Federal Way Police Department, under case number 07- 17232.

In addition, the events described all occurred in Federal Way, King County, Washington.

REQUEST FOR BAIL

The State requests that a summons issue directing the defendant to appear in court. Thedefendant' s criminal history includes convictions for Burglary 2 ( 1995), Att. Theft 2 ( 1998), VUFA (Poss. Firearm 2) ( 2006), Expired Veh. License tabs ( 2003), Driving Without Insurance2003), Fail to display vehicle license (2003), DWLS .3 ( 2003, 2001 x2, 1999, 1998 x 4, 1997 x2,

1996), Assault ( 1997), Theft (1996), NVOLOP ( 1996), Obstruction ( 1999), Poss. Marijuana2001), Following too close (2001).

Signed this day of January, 2008.

Prosecuting Attorney CaseSummary and Request for Bailand/or Conditions of Release - 1

Deanna Jennings Fuller, WSBA #7914

Daniel T. Satterberg, Prosecuting AttorneyW554 King County Courthouse516 Third Avenue

Seattle, Washington 98104206) 296 -9000, FAX (206) 296 -0955

FILED

09 FEB 27 PM to 25

X, ING COUNTYSUP_ RiOR COURT CLERK

KENT. WA

COMMITMENT

SUPERIOR COURT OF WASHINGTON FOR KING COUNTY

STATE OF WASHINGTON,

Vs.

NAAMAN JAMAL WASHINGTON

Plaintiff,

Defendant,

No. 08- 1- 00262 -1 KNT

JUDGMENT AND SENTENCEFELONY ( FJS)

L HEARING

I. 1 The defendant, the defendant' s lawyer, JAY BERNEBURG, and the deputy prosecuting attorney were presentat the sentencing hearing conducted today. Others present were:

II. FINDINGS

There being no reason why judgment should not be pronounced, the court finds: 2. 1 CURRENT OFFENSE( S): The defendant was found guilty on Z —ZC—O by plea of:

Count No.: I Crime: CONSPIRACY TO COMMIT VIOLATION OF THE UNIFORMCONTROLLED SUBSTANCES. ACT/ DELIVER. MDMA(ECSTACY) RCW 9A.28. 040, 69. 50. 101 & 69. 50.407 Crime Code: 37326Date of Crime: 11/ 23/ 2007 Incident No. .

Count No.: II Crime: VIOLATION OF THE UNIFORM CONTROLLED SUBSTANCES ACT/ POSSESS MDMA(ECSTACY) RCW 69. 50.4013 Crime Code: 07348Date of Crime: 11/ 23/ 2007 Incident No. Q 4--- i 4' Z.3

Count No.: Crime: RCW

Crime Code: Date of Crime: Incident No.

Count No.: Crime:

RCWCrime Code:

Date of Crime: • Incident No.

Additional current offenses are attached in Appendix A

Rev. 2/ 09 -. fdw

SPECIAL VERDICT or FINDING(S):

a) [ ]. While armed with a firearm in count(s) RCW 9. 94A.510( 3). b) [ ] While armed with a deadly weapon other than a firearm in count( s) RCW 9.94A.5I0(4). c) [ ] With a sexual motivation in counts) RCW 9. 94A.835. d) [ 1A V.U.C. S.A offense committed in a protected zone in count(s) RCW 69. 50.435. e) [ ] Vehicular homicide [ ] Violent traffic offense [ ] DUI [ ] Reckless [ ] Disregard. . f) [ ] Vehicular homicide by DUI with prior conviction(s) for offense( s) defined in RCW 41. 61. 5055,

RCW 9.94A.510( 7). g) [ ] Non - parental kidnapping or unlawful imprisonment with a minor victim. RCW 9A.44. 130. h) [ ] Domestic violence offense as defined in RCW 10. 99. 020 for count(s) i) [ ] Current offenses encompassing the same criminal conduct in this cause are count(s) RCW

9. 94A.589( 1)( a).

2.2 OTHER CURRENT CONVICTION(S): Other current convictions listed under different cause numbers usedin calculating the offender score are ( list offense and cause number):

2. 3 CRIMINAL HISTORY: Prior convictions constituting criminal history for purposes of calculating theoffender score are (RCW 9. 94A.525):

X] Criminal history is attached in Appendix B. One point added for offense( s) committed while under community placement for count(s)

2. 4 SENTENCING DATA:

SentencingData

Offender

ScoreSeriousnessLevel

StandardRange Enhancement

Total Standard

Range

Maximum

TermCount 1 3 UNRANKD 0 TO 12

MONTHS0 TO 12MONTHS

5 YRS

AND /OR

10, 000Count II 3 1 6+ TO 18

MONTHS6+ TO 18

MONTHS5 YRS

AND /OR

10, 000Count

Count

Additional current offense sentencing data is attached in Appendix C.

2. 5 EXCEPTIONAL SENTENCE (RCW 9.94A.535): Substantial and compelling reasons exist which justify a sentence above/ below the standard range for

Count(s) . Findings of Fact and Conclusions ofLaw are attached inAppendix D. The State [ ] did [ ] did not recommend a similar sentence.

III. JUDGMENT

IT IS ADJUDGED that defendant is guilty of the current offenses set forth in Section 2. 1 above and Appendix A. The Court DISMISSES Count(s)

Rev. 2/ 09 - fdw 2

IV. ORDER

IT IS ORDERED that the defendant serve the determinate sentence and abide by the other terms set forth below.

4. 1 RESTITUTION AND VICTIM ASSESSMENT:

Defendant shall pay restitution to the Clerk of this Court as set forth in attached Appendix E. Defendant shall not pay restitution because the Court finds that extraordinary circumstances exist, and thecourt, pursuant to RCW 9. 94A.753( 2), sets forth those circumstances in attached Appendix E. Restitution to be determined at future restitution hearing on (Date) at m.

Date to be set.

Defendant waives presence at future restitution hearing( s). Restitution is not ordered.

Defendant shall pay Victim Penalty Assessment pursuant to RCW 7. 68. 035 in the amount of $500.

4. 2 OTHER FINANCIAL OBLIGATIONS: Having considered the defendant' s present and likely futurefinancial resources, the Court concludes that the defendant has the present or likely future ability to pay thefinancial obligations imposed. The Court waives financial obligation(s) that are checked below because thedefendant lacks the present and future ability to pay them. Defendant shall pay the following to the Clerk of thisCourt:

a) [ . ] $ , Court costs; [ ] Court costs are waived; (RCW 9. 94A.030, 10. 01. 160)

b) $ 100 DNA collection fee ( RCW 43. 43. 754)( mandatory for crimes committed after 7/ 1/ 02);

c) [ ] $ , Recoupment for attorney' s fees to King County Public Defense Programs; Recoupment is waived (RCW 9.94A.030);

d) [ ] $ , Fine; [ 1$ 1, 000, Fine for VUCSA; VUCSA fine waived (RCW 69.50.430);

e) [ ] $ , King County Interlocal Drug Fund; RCW 9.94A.030)

2,000, Fine for subsequent VUCSA;

Drug Fund payment is waived;

f) [ ] $ , State Crime Laboratory Fee; [ ] Laboratory fee waived (RCW 43.43. 690);

g) [ ] $ , Incarceration costs; [ ] Incarceration costs waived (RCW 9.94A.760(2));

h) [ ] $ , Other costs for:

4. 3 PAYMENT SCHEDULE: Defendant' s TOTAL FINANCIAL OBLIGATION is: $ '' O) . The

payments shall be made to the King County Superior Court Clerk according to the rules of the Clerk and thefollowing terms: [ ] Not less than $ per month; j)(] On a schedule established by the defendant' sCommunity Corrections Officer or Department of Judicial Administration (DJA) Collections Officer. Financialobligations shall bear interest pursuant to RCW 10. 82. 090. The Defendant shall remain under the Court' sjurisdiction to assure payment of financial obligations: for crimes committed before 7/ 1/ 2000, for up toten years from the date of sentence or release from total confinement, whichever is later; for crimescommitted on or after 7/ 1/ 2000, until the obligation is completely satisfied. Pursuant to RCW 9.94A.7602, if the defendant is more than 30 days past due in payments, a notice ofpayroll deduction may be issued withoutfurther notice to the offender. Pursuant to RCW 9. 94A.760( 7)( b), the defendant shall report as directed by DJAand provide financial information as requested.

Court Clerk' s trust fees are waived. Interest is waived except with respect to restitution.

Rev. 2/ 09 - fdw 3

4.4 CONFINEMENT ON E. YEAR OR LESS: Defendant shall serve a term of confinement as follows, commencing: [ ] immediately; [ ] ( Date): 3 -23 —0 -1 by 4 a.m. /2.m.: 6 . nths days on count . 6 on days on count.-1; - ; months/ days on count

This term shall be served:

in the King County Jail or if applicable under RCW 9. 94A. 190( 3) in the Department ofCorrections. k] in King County Work/Education Release subject to conditions of conduct ordered this date.

in King County Electronic Home Detention subject to conditions of conduct ordered this. date. For burglary or residential burglary offense, before entering Electronic Home Detention , 21 daysmust be successfully completed in Work/Education Release.

The terms in Count( s) No. are consecutive/ concurrent.

This sentence shall run [ ] CONSECUTIVE XCONCURRENT to the sentence( s) in cause

The sentence( s) herein shall run [ ] CONSECUTIVE [ ] CONCURRENT to any other term previouslyimposed and not referenced in this order. Credit is given for [ ] day( s) served [ ] days determined by the King County Jail solely forconfinement under this cause number pursuant to RCW 9. 94A.505( 6). [ ] Jail term is satisfied; defendant shallbe released under this cause. ALTERNATIVE CONVERSION PURSUANT TO RCW 9.94A.680: ° days of confinement arehereby converted to:

he 24 0 days/ hours community service under the supervision of the Department of Corrections tobe completed: kron a schedule established by the defendant' s Community CorrectionsOfficer; or [ ] as follows:

Alternative conversion was not used because: [ ] Defendant' s criminal history, [ ] Defendant' sfailure to appear, [ ] Other:

4. 5 COM MUNITY [ ] SUPERVISION, for crimes committed before 7 -1 - 2000, j$(fCUSTODY, for crimescommitted on or after 7 -1 - 2000, is ordered pursuant to RCW 9.94A.545 for a period of 12 months. The .

defendant shall report to the Department of Correctionswithin 72 hours of this date or ofhis/her release if nowin custody; shall comply with all the rules, regulations and conditions of the Department for supervision ofoffenders (RCW 9.94A.720); shall comply with all affirmative acts required to monitor compliance; shall notpossess any firearms or ammunition; and shall otherwise comply with terms set forth in this sentence.

The court finds that chemical dependency contributed to this offense justifying treatment conditionsimposed herein (RCW 9. 94A.607).

Appendix F, Additional Conditions is attached and incorporated. 4. 6 [ ] NO CONTACT: For the maximum term of years, defendant shall have no contact with

4.7 DNA T ESTING. The defendant shall have a biological sample collected for purposes of DNA identificationanalysis and the defendant shall fully cooperate in the testing, as ordered in Appendix G.

HIV TESTING: For sex offense, prostitution offense, drug offense associated with the use ofhypodermic needles, the, defendant shall submit to HIV testing as ordered in Appendix G.

4. 8 [ ] OFF - LIMITS ORDER: ( known drug trafficker) Appendix I is an off limits order that is part of andincorporated by reference. into this Judgment and Sentence.

4. 9 [ ] SEX OFFENDER REGISTRATION: ( sex offense nviction) Append' J cpveringregis tion, is ttached and incorporat by reference ' o this Judgment and S

vDate:

Presented by:

Deputy. Prosecuting Attmey, WSBA# 3 3Print Name: f . f Pi X37

Rev. 04/ 03 4

JUDGE

Print Name:

ex offender

orney for DName:

FINGERPRINTS

RIGHT HAND

FINGERPRINTS OF: DEFENDANT' S ADDRESS: tkab DS3A0k14/ 5Vt W( '( O'

NAAMAN JAMAL WASHINGTON

2‘. 6

PT.It'lVe"

DEFENDANT' S SIGNATUREY g\ c)

TED:

JUDGE, KING COUNTY SUPERIOR COURT

ATTESTED BY: BARBARA MINER,

SUPERIOR COURT CLERKBY:

DEPUTY dftte" Y

CERTIFICATE

1,

OFFENDER IDENTIFICATION

S. I. D. NO. WA17680137CLERK OF THIS COURT, CERTIFY THATTHE ABOVE IS A TRUE COPY OF THE DOB: JULY . 26, 1977

JUDGEMENT AND SENTENCE IN THISACTION ON RECORD IN MY OFFICE. SEX: M

DATED:

RACE: B

BY:

CLERK

DEPUTY CLERK

SUPERIOR COURT OF WASHINGTON FOR KING COUNTYSTATE OF WASHINGTON, )

Plaintiff, ) No. 08- 1- 00262 -1 KNT

vs. )

NAAMAN JAMAL WASHINGTON )

Defendant, )

1)

APPENDIX G

ORDER FOR BIOLOGICAL TESTINGAND COUNSELING

DNA IDENTIFICATION (RCW 43.43.754):

The Court the defendant to cooperate with the King County Department of AdultDetention, King County Sheriff' s Office, and/ or the State Department of Corrections inproviding a biological sample for DNA identification analysis. The defendant, if out ofcustody, shall promptly call the King County Jail at 296 -1226 between 8: 00 a.m. and 1: 00p.m., to make arrangements for the test to be conducted within 15 days.

2) IRV TESTING AND COUNSELING (RCW 70.24.340):

Required for defendant convicted of sexual offense, drug offense associated with theuse of hypodermic needles, or prostitution related offense.)

The Court orders the defendant contact the Seattle -King County Health Departmentand participate in human immunodeficiency virus (HIV) testing and counseling inaccordance with Chapter 70. 24 RCW. The defendant, if out of custody, shall promptlycall Seattle -King County Health Department at 205 -7837 to make arrangements for thetest to be conducted within 30 days.

If (2) is checked, two independent biological samples shall be taken.

Date:

APPENDIX. G —Rev. 09/ 02

ty Superior Court

SUPERIOR COURT OF WASHINGTON FOR KING COUNTY

STATE OF WASHINGTON,

vs.

NAAMAN JAMAL WASHINGTON

Plaintiff,

Defendant,

No. 08 -1- 00262 -1 KNT

JUDGMENT AND SENTENCEAPPENDIX H

COMMUNITY PLACEMENT ORCOMMUNITY CUSTODY

The Defendant shall comply with the following conditions of community placement or community custody pursuantto RCW 9. 94A.700(4), ( 5):

1) Report to and be available for contact with the assigned community corrections officer as directed; 2) Work at Department of Corrections- approved education, employment, and/ or community service; 3) Not possess or consume controlled substances except pursuant to lawfully issued prescriptions; 4) Pay supervision fees as determined by the Department of Corrections; 5) Receive prior approval for living arrangements and residence location; 6) Not own, use, or possess a firearm or ammunition. (RCW 9. 94A.720( 2)); 7) Notify community corrections officer of any change in address or employment; and8) Remain within geographic boundary, as set forth in writing by the Department of Corrections Officer or as set

forth with SODA order.

OTHER SPECIAL CONDITIONS: The defendant shall not consume any alcohol. Defendant shall have no contact with:

Defendant shall remain [ ] within [ ] outside of a specified geographical boundary, to wit:

X] The defen•. t shall participate in . e following crime - related treatment or counseling service: CO V 111 ' n

titF prays . -e proo-f -- CThe defendant shall comply with the following crime- related prohibitions:

Other conditions may be imposed by the court or Department during community custody.

Community Placement or Community Custody shall begin upon completion of the term( s) of confinement imposedherein or when the defendant is transferred to Community Custody in lieu of earned early release. The defendantshall remain under the supervision of the Department of Corrections and follow explicitly the instructions andconditions established by that agency. The Department may require the defendant to per • - .. rn .. rive actsdeemed appropriate to monitor compliance with the conditions [RCW 9. 94A.720] . . may issue wa .. ts and/ ordetain defendants who violate a condition [RCW 9. 94A. 740].

Date:

APPENDIX H -- Rev. 09/ 02

SUPERIOR COURT OF WASHINGTON FOR KING COUNTY

STATE OF WASHINGTON,

S.

NAAMAN JAMAL WASHINGTON

Plaintiff,

Defendant,

No. 08 -1- 00262 -1 KNT

JUDGMENT AND SENTENCE, FELONY) - APPENDIX B,

CRIMINAL HISTORY

2. 2 The defendant has the following criminal history used in calculating the offender scoreRCW 9. 94A.525):

Crime

FIREARM POSSESSION UNL -2BURGLARY 2ND DEGREE

Sentencing Adult or CauseDate Juv. Crime Number Location4/ 7/ 2006 ADULT 051092927 KING CO1/ 12/ 1996 ADULT 951070031 KING CO

The following prior convictions were counted as one oscore ( RCW 9. 94A.525( 5)):

Appendix B —Rev. 09/ 02

termining the offender

GE, KING

1^

SUPERIOR COURT

C s J JG— C) r;S!

The above named patient herby authorizes the above named Designated Provider as his /her legallyrecognized Designated Provider as stipulated under RCW 69. 51A and this document is a legally binding

S oo contract between the parties. The patient herby authorizes the Designated Provider to obtain, grow, l' secure, prepare, repackage and transport medical cannabis for the patient. This agreement further

authorizes the Designated Provider to obtain, secure and transport any other medication recommendedor prescribed by the patients medical providers.

5N't This agreement becomes effective upon execution by the patient and expires upon either the patient' s

y- J written revocation of the agreement by the patient, or upon the patient' s death. 5

This authorization is exclusive to, and solely valid within, the legal boundaries of the state ofWashington.

d —ice d- o sorceress. S ED PROVIDER AUTHORIZATIONDE iGNAT

Prusuant to the Washington Medical Cannabis Act RCW 69. 51A

Patient Name:

Address

S&`- St 1/ --

J e )-? a2

LJ 7 P5/0'Y

AGREEMENT

Designated Provider Name:

WV Lk, ) ( K? Dit(

Address

1 Z MC Sc7»

11 Ski 1 nLO ZS )

A This agreement is not transferable, assignable, or otherwise extended to assignees or designates.

Ni

CAThe patient agrees to defend and hold harmless the Designated Provider and gives full authority to the

L Designated Provider to carry out the action specified herein. I further testify that I am of sound mind atthe time of this agreement and have been given an opportunity to review this document prior to signingand authorizing the power described herein.

8 - Patient Signature:

ate:

Designated Provider Signature:

ey /y/ / O Date:

WASHINGTON DRIVER LICENSELIC # : COLE *LET98NU ExP 98. 31_- 2913,` COLE;LATOYA EVETTE2,9317 18TH AVE S ApT a . FEDERAL WAY WA 98993998CDL _ END RESSEX H " Wr EYES

5-92 1l9 BRN.., ISSUeDQTE 9731 -299! D os 98- 31. 19$ 1