LPOLIC: 1;1 - • '. ' • •': :' Name) - • . • - • • . . (Addrjfsi) .. WV. -'-q.i. Mi\s"iteriaay swear that on or poll . ' •.(City Statek. •• .• • (Dte) . •'. me as )OC -fvcz.( ..E .p cit — tr.,n. . . MATERIAL WITNESS -STATEMENT AFFICWITOFjPROECUTION pAL*.BEACH'; . • 'PpLiap•oEpA9TMEO person-.or persons unknown (4 committed against my•Will.: , the following act(s):', . • 1:5.(A _V 1,‘,(1• 00 (x_ n,nrk -,c::t cv2. Pe_ fq t LeA acy-) , • Ilx -). b•-)11,R,e \ Masweved \r\i5 \-xac . Saw 1- A\ ex -,, ..- (iv - Int \rm kroocick I do ( do not: ( ) defi3ire to pros te and take what step are necess ry for police action.. Date: 01"),0,6 . • ii tpis --!, ' day of -5`, I1 - IFIIIMUIII11 S orn to and Subscribedlrfore m ..' • 44 it A.,--------- we'tri:14.—. te-- Case#: Of ficer/Notary Signature Title 0 WI."' • . CONFIDENTIAL MM22-POCKET FOLDER-000010 3501.189-001 Page 1 of 1 EFTA_00072870 EFTA01248300