Form CJ1902 is a form used to report certain types of criminal activity. This form is used to report crimes that have been committed, are being committed, or are about to be committed. The information reported on this form will help law enforcement officials investigate and prosecute criminal activity. If you have any information about a crime, please fill out Form CJ1902 and submit it to the authorities. Thank you for your help in keeping our community safe!
| Question | Answer |
|---|---|
| Form Name | Form Cj1902 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | notice of peace officer separation of service, ohio opota form sf401, sf401adm forms, fillable sf401 |
NOTICE OF OFFICER SEPARATION
FORM CJ1902
REVISED 08/21/2012
IN ACCORDANCE WITH RCW 43.101.135 & RCW 43.101.157
THIS FORM MUST BE SUBMITTED TO THE WSCJTC WITHIN 15 DAYS OF SEPARATION.
WE REQUEST THAT YOU SEND THIS FORM BY FAX OR EMAIL.
QUESTIONS: 206‐835‐7332 |
FAX: 206‐835‐7923 |
EMAIL: tjones@cjtc.state.wa.us |
With the exception of the signature box, this form must be typed.
AGENCY:
RANK:
PEACE OFFICER’S FULL NAME:
Female
Male
DATE OF BIRTH (MM/DD/YY):
HIRE DATE (MM/DD/YY):
SOCIAL SECURITY NUMBER:
SEPARATION DATE (MM/DD/YY):
REASON FOR SEPARATION:
Retired, in good standing |
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Resigned, in good standing |
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Terminated, involuntary |
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Medical |
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Deceased |
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Resigned, in anticipation of termination |
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Retired, in anticipation of termination |
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Laid off
Is this agency aware of conduct that may fall under the meaning of “Disqualifying Misconduct” as defined below:
RCW 43.101.010
(7)A peace officer is "convicted" at the time a plea of guilty has been accepted, or a verdict of guilty or finding of guilt has been filed, notwithstanding the pendency of any future proceedings, including but not limited to sentencing, post trial or post fact‐finding motions and appeals. "Conviction" includes a deferral of sentence and also includes the equivalent disposition by a court in a jurisdiction other than the state of Washington.
(8)"Discharged for disqualifying misconduct" means terminated from employment for: (a) Conviction of (i) any crime committed under color of authority as a peace officer, (ii) any crime involving dishonesty or false statement within the meaning of Evidence Rule 609(a), (iii) the unlawful use or possession of a controlled substance, or (iv) any other crime the conviction of which disqualifies a Washington citizen from the legal right to possess a firearm under state or federal law; (b) conduct that would constitute any of the crimes addressed in (a) of this subsection; or (c) knowingly making materially false statements during disciplinary investigations, where the false statements are the sole basis for the termination.
(9)A peace officer is "discharged for disqualifying misconduct" within the meaning of subsection (8) of this section under the ordinary meaning of the term and when the totality of the circumstances support a finding that the officer resigned in anticipation of discipline, whether or not the misconduct was discovered at the time of resignation, and when such discipline, if carried forward, would more likely than not have led to discharge for disqualifying misconduct within the meaning of subsection (8) of this section.
(MUST CHECK YES OR NO)
YES
NO
RCW 43.101.135 requires the agency of termination, to provide such documentation or information as the commission deems necessary and requests to investigate and determine whether the separation provides grounds for revocation under RCW 43.101.105.
Employee’s last known mailing address, email address, and phone number:
Agency investigative contact person (Name, title, phone number, and email):
I declare under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct to the best of my knowledge.
Appointing official (name, title, phone and email:
Signature of above
Date
FOR WSCJTC USE ONLY
Date entered into LMS: