Community Service Verification Form - Kirkland Municipal Court printable pdf download

KIRKLAND MUNICIPAL COURT

COMMUNITY SERVICE VERIFICATION FORM

Defendant: ______________________________________

Court Case #:_______________________

Date Imposed: ________________ Date Due: _______________ Total CSE Hours: ______________

Defendant may complete above community service in lieu of fines.

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To perform community service for the Municipal Court, you must adhere to the following:

1. Community service hours must be performed at a non-profit agency with an active 501(c) status. This

includes most charities, government agencies, public schools, libraries, parks, food banks, and shelters

etc. You must verify the agency is non-profit and you may not receive any payment for your community

service.

2. The Court will not accept community service performed for a prior or current employer, family member

or an agency for which you have management responsibility. This court does not accept community

service hours from online agencies or from agencies in which you must pay a fee to get credit for your

hours (some examples of this include, but are not limited to: Terra Research, Community Service Help,

Fast Community Service, American Angel Works, Caffeine Awareness Association).

3. The organization with which you perform community service must complete this form AND attach a letter

of verification of hours worked (see sample on reverse side) including the dates the services were

performed by you. The verification letter must be on the non-profit agency’s letterhead.

I certify under penalty of perjury under the laws of the State of Washington that ___________________

__________________________________is a non-profit agency, and that the individual identified herein

performed the community service hours at this agency as set forth in the attached verification letter.

Non – Profit Agency Number (EIN Number): ________________________________________________

Agency Contact and Title: ______________________________________ Telephone: _______________

Address: ____________________________________________________________________________

Signature :______________________________________________ Date: _______________________

NOTE TO ORGANIZATION: Please be advised that we may contact you to verify hours & dates of services performed

by this defendant.

I certify under penalty of perjury under the laws of the State of Washington that (1) I am the defendant in

this case; (2) I performed the community service hours at the described non-profit agency on the dates and

times described in the attached verification letter.

Signature: _____________________________________________ Date: ________________________

NOTE TO DEFENDANT: Hours that are filed late, incomplete or that do not have a service verification letter may not

fulfill your requirement and may result in a review hearing. False certifications may be grounds for a referral for future

criminal charge, contempt of court and/or grounds for a violation of probation.

FOR COURT USE ONLY

☐

Approved

Denied

________________________________________________

(Court Clerk Signature)

KIRKLAND MUNICIPAL COURT PROBATION DEPARTMENT

11740 NE 118th Street  PO Box 2543  Kirkland, Washington 98083-2543

425.587.3189  Fax 425.587.3781 

Community Service Verification Form - Kirkland Municipal Court

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