For Volunteer Fire Fighters and Reserve Officers

BEFORE THE WASHINGTON STATE BOARD

FOR VOLUNTEER FIRE FIGHTERS AND RESERVE OFFICERS

In re: / DECLARATION CONCERNING
FIRE DEPARTMENT/DISTRICT
RECORDS

______hereby declares as follows:

1. I am over the age of 18 years and am competent to testify as to the matters contained herein, and that all statements made herein are based upon my own personal knowledge.

2. I am an officer and/or custodian of the records of the below designated fire department or fire district.

3. The attached documents are true, accurate, and unaltered attendance, response, drill and/or training records of the ______fire department/district for the following individuals: ______

______.

I certify under penalty of perjury of the laws of the State of Washington that the foregoing is true and correct to the best of my knowledge and belief.

DATED at ______, Washington this _____ day of ______, 200_.

______

Officer and/or Records Custodian

Subscribed and sworn before me this ______day of ______, ______.

______

Notary Public in and for the State of Washington residing at ______.

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