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BATTERERS INTERVENTION PROGRAM PROVIDERS AFFIDAVIT OF COMPLIANCE to

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BATTERERS’ INTERVENTION PROGRAM PROVIDERS
AFFIDAVIT OF COMPLIANCE
I, {full legal name} ____________________________________ being sworn, certify that I continue
to meet all of the qualifications to be a batterers’ intervention program provider listed in section
741.325, Florida Statutes.
Full Name:
(Print)
Program Name
Business Address:
Email Address:
Phone:
_____________________________________________ ___________________
Signature Date
STATE OF FLORIDA
COUNTY OF ____________________________________
Sworn to or affirmed and signed before me on __________________________________ by
__________________________________.
__________________________________
NOTARY PUBLIC
(Print, type, or stamp commissioned name of notary)
___ Personally known
___ Produced identification
Type of identification produced: _____________________
Remit annually, no later than June 30th, to:
Director of Court Services
Seventh Judicial Circuit
101 N. Alabama Ave., Suite B253
DeLand, FL 32724
or via email to: brinker@circuit7.org
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Completed 21 June 2021

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