We, the jury, find the defendant guilty (or not guilty) of the crime of ____________________ as charged in count number __________.
___________________________________
Signature of Presiding Juror

Was the defendant ______(name)______ armed with a deadly weapon at the time of the commission of the crime charged in count number _____ Yes ( ) No ( )

SUPERIOR COURT OF WASHINGTON
FOR [ ] COUNTY
STATE OF WASHINGTON, ) No.
Plaintiff, ) NOT GUILTY BY REASON OF INSANITY
vs. ) ACQUITTEE’S NOTICE OF
) [X] FIREARM DISABILITY
_______________________, ) [X] TIME LIMITS ON COLLATERAL ATTACKS
Defendant. ) [ ] SEX OFFENDER OR KIDNAPPING
) [ ] OFFENDER REGISTRATION REQUIREMENTS
)
TO THE ABOVE-NAMED DEFENDANT:
You are hereby advised that you have been acquitted by reason of insanity of the offense of ____________________.
YOU ARE ADVISED THAT YOU ARE TO IMMEDIATELY SURRENDER ANY FIREARM AND ANY CONCEALED PISTOL LICENSE AND YOU MAY NOT POSSESS A FIREARM OR A CONCEALED PISTOL LICENSE UNTIL YOUR RIGHT HAS BEEN RESTORED BY A COURT OF RECORD.
You are further advised that if you wish to petition or move for collateral attack on any order of hospitalization or order mandating alternative treatment less restrictive than detention in a state hospital, 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. In re Personal Restraint of Well, 133 Wn.2d 433, 946 P.2d 750 (1997).
If the following numbered paragraphs apply, they should initialed by the Defendant and the Judge.
1. General Applicability and Requirements. Because the offense which you have been acquitted of committing by reason of insanity is classified as a sex offense or kidnapping offense in RCW 9A.44.130, you will be required to register with the sheriff of the county of the state of Washington where you reside. If you are not a resident of Washington but you are a student in Washington or you are employed in Washington or you carry on a vocation in Washington, you must register with the sheriff of the county of your school, place of employment, or vocation. You must register immediately upon being acquitted by reason of insanity 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 you in custody and you must also register within 24 hours of your release with the sheriff of the county of the state of Washington where you will be residing, or if not residing in the state of Washington, where you are a student, where you are employed, or where you carry on a vocation.
2. Offenders Who Leave the State and Return: If you leave this state following your acquittal or release from custody but later move back to Washington, you must register within three business days after moving to this state or within 24 hours after doing so if you are under the jurisdiction of this state’s Department of Social and Health Services. If you leave this state following your acquittal or release from custody, but later while not a resident of Washington you become employed in Washington, carry on a vocation in Washington, or attend school in Washington, you must register within three business days after attending school in this state or becoming employed or carrying out a vocation in this state, or within 24 hours after doing so if you are under the jurisdiction of this state’s Department of Social and Health Services.
3. Change of Residence Within State and Leaving the State: If you change your residence within a county, you must send signed written notice of your change of residence to the sheriff within 72 hours of moving. If you change your residence to a new county within this state, you must send signed written notice of the change of address at least 14 days before moving to the county sheriff in the new county of residence and you must register with the sheriff of the new county within 24 hours of moving. You must also give signed written notice of your change of address to the sheriff of the county where last registered within 10 days of moving. If you move out of Washington State, you must send written notice within 10 days of moving to the new state or foreign country to the county sheriff with whom you last registered in Washington State.
4. Additional Requirements Upon 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 10 days after establishing residence, or after beginning to work, carry on a vocation, or attend school in the new state. You must also send written notice within 10 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. Notification Requirement When Enrolling in or Employed by a Public or Private Institution of Higher Education or Common School (K-12): If you are a resident of Washington and you are admitted to a public or private institution of higher education, you shall, within 10 days of enrolling or by the first business day after arriving at the institution, whichever is earlier, notify the sheriff of the county of your residence of your intent to attend the institution. If you become employed at a public or private institution of higher education, You are required to notify the sheriff for the county of your residence of your employment by the institution within 10 days of accepting employment or by the first business day after beginning to work at the institution, whichever is earlier. If your enrollment or employment at a public or private institution of higher education is terminated, you are required to notify the sheriff for the county of your residence of your termination of enrollment or employment within 10 days of such termination. If you attend, or plan to attend, a public or private school regulated under Title 28A RCW or chapter 72.40 RCW, you are required to notify the sheriff of the county of your residence of your intent to attend the school. You must notify the sheriff within 10 days of enrolling or 10 days prior to arriving at the school to attend classes, whichever is earlier. The sheriff shall promptly notify the principal of the school.
6. Registration by a Person Who Does Not Have a Fixed Residence: Even if you do not have a fixed residence, you are required to register. Registration must occur within 24 hours of release in the county where you are being supervised if you not have a residence at the time of your release from custody. Within 48 hours, excluding weekends and holidays, after losing your fixed residence, you must send signed written notice to the sheriff of the county where you last registered. If you enter a different county and stay there for more than 24 hours, you will be required to register in the new county. You must also report in person to the sheriff of the county where you are registered on a weekly basis. The weekly report will be on a day specified by the county sheriff’s office, and shall occur during normal business hours. You may be required to provide a list of the locations where you have stayed during the last seven days. The lack of a fixed residence is a factor that may be considered in determining a sex offender’s risk level and shall make you subject to disclosure to the public at large pursuant to RCW 4.24.550.
7. Reporting Requirements for Persons Who Are Risk Level II or III: If you have a fixed residence and you are designated as a risk level II or III, you must report, in person, every 90 days to the sheriff of the county where you are registered. Reporting shall be on a day specified by the county sheriff’s office, and shall occur during normal business hours. If you comply with the 90-day reporting requirement with no violations for at least five years in the community, you may petition the superior court to be relieved of the duty to report every 90 days.
8. Application for a Name Change: If you apply for a name change, you must submit a copy of the application to the county sheriff of the county of your residence and to the state patrol not fewer than five days before the entry of an order granting the name change. If you receive an order changing your name, you must submit a copy of the order to the county sheriff of the county of your residence and to the state patrol within five days of the entry of the order. RCW 9A.44.130(7).
The warning regarding firearms has been read to the defendant.
DATED:
_________________________
Judge/Commissioner/Pro Tem
_____________________________
Defendant’s Signature
Defendant’s Last Name First Name Middle Name
_______________________________________________________________
List any aliases
_______________________________________________________________
Residential Street Address City State Zip
_______________________________________________________________
Date of Birth (month/date/year) Driver’s License/ID Number
_______________________________________________________________
Race __________ Sex _______ Weight _______ Height ______
Eyes _________ Hair _________
Court NCIC # ___________________________________
Submit to: Dept. of Licensing, Business & Professions Firearms Unit, PO Box 9649, Olympia, WA 98507-9649