By signing below, I certify that I have witnessed the youth listed in the table below receive the incentive as noted.

Name of Agency / Name of Project / Dates of Project
Name of Youth / SYVPI # / Date Paid / Type / Amount/Value / Witness #1 Signature / Witness #2 Signature /
/ cash
check: #
gift card: # / $ /
Print Name and Title / Print Name and Title /
/ cash
check: #
gift card: # / $ /
Print Name and Title / Print Name and Title /
/ cash
check: #
gift card: # / $ /
Print Name and Title / Print Name and Title /
/ cash
check: #
gift card: # / $ /
Print Name and Title / Print Name and Title /
/ cash
check: #
gift card: # / $ /
Print Name and Title / Print Name and Title /
/ cash
check: #
gift card: # / $ /
Print Name and Title / Print Name and Title /
/ cash
check: #
gift card: # / $ /
Print Name and Title / Print Name and Title /
/ cash
check: #
gift card: # / $ /
Print Name and Title / Print Name and Title /
/ cash
check: #
gift card: # / $ /
Print Name and Title / Print Name and Title /
/ cash
check: #
gift card: # / $ /
Print Name and Title / Print Name and Title /
/ cash
check: #
gift card: # / $ /
Print Name and Title / Print Name and Title /
/ cash
check: #
gift card: # / $ /
Print Name and Title / Print Name and Title /
/ TOTAL AMOUNT / $ /

Seattle Youth Violence Prevention Initiative

Youth Incentive Payout Certification

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