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GENE DANA, SHERIFF <br />KITTITA.S COUNTY SHERIFF'S OFFICE <br />307 W. Umptanum Rd + Ellensburg, WA 98926 <br />(509) 962-7525 + (509) 674-2584 <br />FAX (509) 962-7599 <br />Statement of Physical Custody of 1033 Program Property <br />Lary Enforcement Agency Information; <br />Name: Kittitas County Sheriffs Office <br />Address: 307 W. Umptanum Rd., Ellensburg, WA 98926 <br />Phone Number: 509-962-7525 <br />1033 Property Issued to: <br />Name: <br />1033 Property: <br />NSN: <br />MAKE: <br />Last Name, First Name <br />ITEM NOMENCLATURE: Required Entry <br />MODEL: <br />SERIAL NUMBER: <br />ITEM UNIT COST: <br />QTY OF ITEM: <br />Required Entry <br />Required Entry <br />Statement of Physical Custody <br />d71 <br />I am a Law Enforcement Officer of the aforementioned Law Enforcement Agency. I have physical <br />custody of the item(s) listed above and accept personal responsibility for the property. I further <br />understand that failure on my part to exercise responsibility for the care and protection of the <br />item(s) listed above could result in pecuniary liability. <br />PRINTED NAME: <br />SIGNATURE: DATE: <br />