WA State Department of Commerce 10/5/2016

Consultation with Victim Services (criminal justice agencies only) State applications to the Office on Violence Against Women are required to show documentation that criminal Justice agencies receiving STOP Grant funds have consulted with their local non-profit community-based victim service programs during the course of developing applications. This requirement is to ensure that proposed activities by criminal justice agencies are designed to promote the safety, confidentiality,and economic Independence of victims of domestic violence,sexual assault,stalking,and dating violence. As verification that applicant has consulted with the local Community Sexual Assault Program(CSAP)and the Department of Social and Health Services Shelter Funded Domestic Violence Agency during the development of this application,this form must be signed by the Executive Director of the appropriate victim service provider(s). The criminal Justice agency must provide the signed form(s)to Amy Thome at OCVA via fax(360.586.7176)or scanned and emailed to Amy Thome at amy.thome@cornmerce.wa.dc v before the application can be approved by OCVA. In counties where the CSAP is separate from the DSHS shelter funded domestic violence agency,applicant can print two copies of this form to enable both Executive Directors to respond and sign. APPLICATION FOR LAW ENFORCEMENT AND/OR PROSECUTOR(as applicable): Everett Police Department Name of Criminal Justice Applicant Victim Service Provider: Please answer the following questions,sign this form and return It to the applicant. Every effort should be made to resolve concerns prior to the applicant submitting to OCVA. Did you participate in the development of this application? (. Yes C No Do you agree the proposed criminal justice activities promote the safety, (; Yes C No confidentiality,and economic independence of victims? If you do not agree the proposed activities are in the best interest of victims,have you been given the opportunity to provide feedback to (i Yes C No the applicant? If you provided feedback,are you satisfied that the application addresses (; Yes C No Issues you may have asked to be included? If you answered"no"to any of the above,please provide details regarding the process and steps necessary to address concerns with the application. Providence intervention Center for Assault and Abuse Communit Sexual Assault Program(CSAP)Name • Signature of Ext cutivF ,i .N, Domestic Violence Services of Snohomish County Department of Social and Health Services Shelter Funded Domestic Violence Agency Name Signature of Executive Director