Wash. Rev. Code § 59.18.575

. . . .
[Name of organization, agency, clinic, professional service provider]

I and/or my . . . . . . (household member) am/is a victim of

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. . . domestic violence as defined by RCW 7.105.010.

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. . . sexual assault as defined by RCW 70.125.030.

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. . . stalking as defined by RCW 9A.46.110.

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. . . unlawful harassment as defined by RCW 59.18.570.

Briefly describe the incident of domestic violence, sexual assault, unlawful harassment, or stalking:. . . .
. . . .

The incident(s) that I rely on in support of this declaration occurred on the following date(s) and time(s) and at the following location(s): . . . ..

The incident(s) that I rely on in support of this declaration were committed by the following person(s): . . . .
. . . .

I state under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct. Dated at . . . . . . . . . . (city) . ., Washington, this . . . day of . . . ., . . . . (year)

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. . . .
Signature of Tenant or
Household Member

I verify that I have provided to the person whose signature appears above the statutes cited in RCW 59.18.575 and that the individual was a victim of an act that constitutes a crime of domestic violence, sexual assault, unlawful harassment, or stalking, and that the individual informed me of the name of the alleged perpetrator of the act. I further verify that I have informed the person whose signature appears above that information about the landlord mitigation program can be found on the website established pursuant to RCW 43.31.605(11), including the form developed pursuant to RCW 43.31.605(1)(d)(iv).
Dated this . . . day of . . . ., . . . . (year)

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