Free F416-016-000 statement - Washington


File Size: 112.7 kB
Pages: 3
Date: October 25, 2006
File Format: PDF
State: Washington
Category: Government
Author: Forms Management
Word Count: 326 Words, 2,182 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.lni.wa.gov/Forms/pdf/416016a0.pdf

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Preview F416-016-000 statement
Department of Labor and Industries Division of Occupational Safety and Health PO Box 44600 Olympia WA 98504-4600

STATEMENT
Page 1 of _____Pages , reside at in the

I,
(number) (street)

City of State of My telephone is Area Code I have been employed by located at
(number) (street)

, County of ZIP code of ( )

(city)

(state)

(ZIP+4)

Office telephone Area Code is (was) Statement: I hereby depose and say:

(

)

My job classification

F416-016-000 statement 10-06

STATEMENT (continued) Statement of _______________________________________________________ Page _____ of _____ pages

F416-016-000 statement 10-06

STATEMENT (affirmation) Statement of _______________________________________________________ Page _____ of _____ pages

Witness:
I request my identity not be disclosed. My identity may be disclosed upon request. I understand that, if I request confidentiality, my identity will be held in confidence until such time as I may be called to testify in a court proceeding, at which time it may be produced upon demand of opposing counsel. Additionally, this entire statement may be made available to other agencies if it will assist them in the performance of their statutory functions. This statement may be subject to disclosure only in accordance with applicable statutes such as WISHA, the Washington Public Disclosure Act and agency policy. I also understand that RCW 49.17.160 of the Washington Industrial Safety and Health Act (WISHA) prohibits my employer from discriminating against me in any way because I have voluntarily furnished this information to the Department of Labor and Industries. If such discrimination or retaliation by my employer occurs as a result of my making a statement, I may file a WISHA discrimination complaint with the department. I declare under penalty of perjury of the laws of the state of Washington that the foregoing is true and correct. I also understand that I may be criminally prosecuted pursuant to RCW 49.17.190 (2) for false statements.
Date Name (printed) Signature

Address, City, State and ZIP where signed Phone

(

)
Signature

Signature witnessed by: Date Name (printed) Title

F416-016-000 statement 10-06