Community Support Solutions

PO Box 1237 Edmonds, WA 98020

 425-672-8787, Fax 425-670-1640

     Electronic Visit Verification Form

Client: _____________________________________ Date:______________________

I give Community Support Solutions permission to use the phone numbers and physical address listed below for the sole purpose of complying with the electronic visit verification requirement that is Washington State Law.

Phone number 1 (Main Number to be used):         ______________________________

Phone number 2 (Back up number 1):                   ______________________________

Phone number 3 (Back up number 2):                   ______________________________

Client Physical Address:__________________________________________________

                                      ___________________________________________________

Signature: _________________________________ Date: ______________________

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Document name: Electronic Visit Verification Form

Unique Document ID: ceeb779c06629e7754236f572be1575ff4cccff3

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Timestamp	Audit
March 17, 2023 5:49 pm PDT	Electronic Visit Verification Form Uploaded by Priscilla Monahan - Priscilla@cssow.com IP 172.92.214.196

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