IF A VALID PROTECTIVE ORDER IS ATTACHED TO THIS FORM, A CERTIFYING AGENCY OR OFFICER DOES NOT NEED TO COMPLETE THE FOLLOWING SECTIONS.

This letter serves to certify that ___________________________(Name of Applicant for Service) is a victim of domestic violence, stalking, or harassment, as defined in Section 109 of Title 43 of the Oklahoma Statutes or Section 644 of Title 21 of the Oklahoma Statutes, and therefore has demonstrated satisfactory credit for the purposes of establishing service. The requirement of initial deposit shall be waived for the above named customer. (Only one Certifying Agency is required.)

By my signature, I certify that the following Certifying Agency has determined that, based on the information gathered at the time of intake/assessment/provision of services, the above-named Applicant reported experiences of domestic violence and was assessed to be a victim of domestic violence.

Agency Name: ______________________________

Contact Number: ______________________________

Signature: ______________________________

Printed Name: ______________________________

Title: ______________________________

Date: ______________________________

By my signature I certify that I have personally responded to or have confirmed via internal records that an officer of the _____________________________ Police Department has responded to an incident occurring within the municipal boundaries of the _____________________________ (municipality) where the above-named Applicant was reported to be a victim of domestic violence.

Department Representative Signature: ______________________________

Department Representative Printed Name: ______________________________

Badge Number (if applicable): ______________________________

Date: ______________________________

This form expires ninety (90) days from the date of the signature of the certifying individual.