Superior Court of Washington County of State of Washington, Plaintiff, vs. ____________________________, Defendant. SID: If no SID, use DOB: Criminal Case No.:__________________ Civil Case No.:_____________________ Petition for Certificate and Order of Discharge (PFCORD) [ ] and for Issuance of a Separate NoContact Order (PCORDN) Clerk's Action Required: [ ] Filing fee received for civil case number Note to defendant: A Certificate and Order of Discharge does not operate to remove a criminal Conviction from your record. It does not remove any restrictions on the ownership, possession or control of firearms/ammunition under state/federal law. A Certificate and Order of Discharge does not terminate your obligation to comply with a no-contact order that excludes or prohibits you from having contact with a specified person or coming within a set distance of any specified location or your obligation to register as a sex or kidnapping offender. I, ______________________ (name of defendant) petition the court for a Certificate and Order of Discharge [ ] and for Issuance of a Separate No-Contact Order pursuant to RCW 9.94A.637. I have completed all requirements imposed on me by the court in the Judgment and Sentence imposed in this case, including the payment of legal financial obligations, restitution, principal and interest, as well as all applicable collection costs. If I am subject to a no-contact order that was written as part of and included in the judgment and sentence, I request the court to reissue the no-contact order separately for the remaining term and under the same conditions as contained in the judgment and sentence. I declare under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct. Signed at _______________________, (City) ____________ (State) on ____________________ (Date). ____________________________________ Signature of Defendant Print or Type Name Pt. for Cert./Or of Discharge (PFCORD, PCORDN) - Page 1 of 2 WPF CR 08.0600 (12/2010) RCW 9.94A.637 American LegalNet, Inc. www.FormsWorkFlow.com ------------------------------------------------------------------------------------------------------------------------------Confirmation of Court-ordered Requirements: I have checked the Department of Corrections records and the records show that the defendant [ ] has [ ] has not satisfactorily completed all court-ordered requirements. I declare under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct. Signed at (city) ________________________, (state) _____________ on (date) ___________________. ____________________________________ Signature of Community Corrections Officer OR I am submitting the following materials to show that I have completed the requirements of the Judgment and Sentence, such as community service hours and substance evaluation/treatment (attach to this document). _________________________________________________________________________________ _________________________________________________________________________________. I declare under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct. Signed at (city) ________________________, (state) _____________ on (date) ___________________. ___________________________________________ Signature of Defendant Pro Se/ Attorney for Defendant/WSBA No. ______________________________ Print Name ________________________________ Print Name ------------------------------------------------------------------------------------------------------------------------------And Confirmation of Legal Financial Obligations: I have checked the Clerk's financial records and the records show that the defendant [ ] has [ ] has not completed the payment of all legal financial obligations (including principal and interest) and all applicable collection costs. I declare under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct. Signed at (city) ________________________, (state) _____________ on (date) ___________________. ____________________________________ Signature of (Deputy) Clerk- Finance section ________________________________ Print Name Pt. for Cert./Or of Discharge (PFCORD, PCORDN) - Page 2 of 2 WPF CR 08.0600 (12/2010) RCW 9.94A.637 American LegalNet, Inc. www.FormsWorkFlow.com