Community Service Verification Form - City Of Lakewood


Lakewood  University Place  Steilacoom  DuPont
6000 Main Street SW  Lakewood, WA 98499
Tel (253) 512-2258  Fax (253) 512-2267
To perform community service for the Municipal Court, you must adhere to the following:
Community service must be performed in person at a NON-PROFIT organization such as a
public school, church, food bank, etc., anywhere within the State of Washington. You must
verify that the agency is a non-profit and you may not receive any payment for your
community service.
Community service hours performed must begin on or after your judgment date. You will
not receive credit for hours performed prior. Community service is credited at $10.00 per
hour when applicable. Any hours completed must be filed ON OR BEFORE your due date.
The organization with which you perform community service must complete this form AND
attach a letter of verification of hours worked, including 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.
EIN (Employer ID Number)____________________________________________
Agency Contact: ____________________________________________________
Telephone: ____________________
Address: _________________________________________________________
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: _____________________________________
NOTE TO ORGANIZATION: Please be advised that we may contact you to verify hours & dates of
services performed by this defendant.
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 warrant for your arrest. False
certifications may be grounds for a referral for future criminal charge, contempt of court and/or
grounds for a violation of probation.
Defendant: ________________________________________________
Court Case #:_____________________
Date imposed:____________
Date due:____________
Total CSE Hours: _________________ in lieu of _________________________________________
Updated 01/22/15


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