Fillable Experience Affidavit YOUR CONTACT INFORMATION Mailing Address (Street, (Washington)

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Experience Affidavit YOUR CONTACT INFORMATION Mailing Address (Street, (Washington)

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The Experience Affidavit YOUR CONTACT INFORMATION Mailing Address (Street, (Washington) form is 3 pages long and contains:

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  • 22 check-boxes
  • 37 other fields

Country of origin: US
File type: PDF

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Page 1
Experience
Affidavit
YOUR CONTACT INFORMATION
Full Name: ______________________________ Washington CPA # if applicable: _________________
Daytime Phone: (______) _______________________
Mailing Address (Street, City, State or Province, Zip Code, and Country)
________________________________________ Email Address: _______________________________
________________________________________ Date of Birth: ________________________________
________________________________________
YOUR CERTIFICATION SECTION
I certify that:
The information on this form is complete and accurate.
_________________________________________ ___________________________
Signature Date
YOUR REQUIRED SKILL AREAS
List the organization(s) where you obtained your work experience (attach additional sheets if necessary):
Dates Worked Dates Worked
From:__________________ To:__________________ From:__________________ To:__________________
Organization: _________________________________ Organization: _________________________________
Industry: _____________________________________ Industry: _____________________________________
Address:_____________________________________ Address: _____________________________________
_____________________________________ _____________________________________
Key Job Responsibilities – Attach a summary and/or resume. Key Job Responsibilities – Attach a summary and/or resume.
Total Number of Hours Worked at this Organization Total Number of Hours Worked at this Organization
(Not total hours per week or month): _______________ (Not total hours per week or month): _______________
Total number of hours worked in all organizations: _____________________ (Must be a minimum of 2,000 hours)
Total number of months worked in all organizations: ___________________ (Must be a minimum of 12 Months)
Page 2
YOUR REQUIRED COMPETENCIES
For each skill set within the competency category (1.1, 1.2, 1.3, 1.4, 2, 3, etc.) you must have observed or applied the skill and
thereby had the opportunity to gain or improve your personal skills and/or abilities. For example, you became aware of legal or
regulatory requirements, professional standards or rules, or organizational policies applicable to your work place; or you have
participated in a program, project, or division or applied appropriate procedures, etc., in which specific competencies and abilities
were demonstrated. You are not expected to have mastered the competency or ability.
The opportunity to gain or improve your personal abilities can be obtained by complying with a job description and/or organization
policies, or as a team member working on or in programs, projects, or divisions.
Each box must be checked under all competencies.
Competency 1 – Assess the Achievement of an Entity’s Objectives
1.1 My work experience(s) required me to plan a daily work schedule or a longer term project or work program to
accomplish a specific result.
1.2 As a result of my experience I became aware of the need for numerical performance measures and utilization such as
measures indicate progress toward desired results (goals) or identify road blocks to achieving desired results.
1.3 As a result of my experience I became aware of the need to recognize conditions that may require the extension or
modification of a plan and objectively and calmly restructure an original plan.
1.4 As a result of my experience I am aware of the need to listen unemotionally but objectively when evaluating verbal or
written input from others.
Competency 2 – Develop Documentation and Sufficient Data to Support Analysis and Conclusions
2. As a result of my experience I became aware of the need to document data and other objective factual matter to support
recommendations and conclusions.
Competency 3 - Understand Transaction Streams & Information Systems
3. My work and life experiences have introduced me to certain accounting routines such as why time cards are kept and
how they flow through to a paycheck, how cash is accounted for, how payments are accounted for, why supervisors check
the detail of a time card or whether all the cash receipts are accounted for or why the bank statement is reconciled to the
checkbook.
Competency 4 – Assess Risk and Design Appropriate Procedures
4.1 As a result of my experience I became aware of the need for assessments of legal, regulatory, financial, and
organizational risk levels and that policies and procedures are designed to mitigate those risks.
4.2 I can recognize when individuals appear to be living beyond their means and can imagine how that might occur whether
legal or illegal.
Competency 5 – Make Decisions, Solve Problems, and Think Critically in the Context of Analysis
5.1 As a result of my experience I became aware that some people make decisions without any basis for the decision. My
work and life experiences have taught me how to be reasonably certain I knew what I was talking about by having some
objective data or other knowledge base to support my position on a matter.
5.2 As a result of my work and life experiences I have a sense of when numbers don’t appear to reflect what I think the
number should be and what I might need to know that will explain why the difference.
Competency 6 - Communicate Scope of Work, Findings and Conclusions Effectively
6. As a result of my work and life experiences I have gained an understanding that you must communicate at the level of
your audience (group) and that the same message can be conveyed in different ways.
Page 3
VERIFYING CPA CERTIFICATION SECTION
If more than one CPA is verifying the experience, please submit additional sheets.
CPAs Full Name: ______________________________________ License #: ____________ State of Issuance: __________
Mailing Address (including city, state, zip code): Daytime Phone: (______)_________________________
____________________________________________________
_____________________________________________________ Email Address: _________________________________
____________________________________________________
I certify that (each box must be checked):
I currently hold a valid license to practice public accounting.
I have held a valid CPA license to practice public accounting in a US jurisdiction for a minimum of five years.
The individual I am verifying provided me the fully completed experience affidavit signed by the individual as the basis for
my verification.
The individual I am verifying has had experience providing the opportunity to attain skills related to the following
competencies (each box must be checked):
Assess the Achievement of an Entity’s Objectives
Develop Documentation and Sufficient Data to Support Analysis and Conclusions
Understanding Transaction Streams & Information Systems
Assess Risk and Design Appropriate Procedures
Make Decisions, Solve Problems, and Think Critically in the Context of Analysis
Communicate Scope of Work, Findings and Conclusions Effectively
_________________________________________ ___________________________
Verifying CPA’s Signature Date
Please submit your experience affidavit with your online license application or mail to:
PO Box 9131, Olympia, WA 98507 Phone: (360) 753-2586
THE BOARD ADVISES YOU TO KEEP COPIES OF ALL DOCUMENTATION SUBMITTED FOR YOUR RECORDS.
Please be advised: The Washington State Board of Accountancy is required to comply with the Public Records Act, Chapter 42.56 RCW.
The information you submit to the Board may ultimately be subject to disclosure as a public record.
Revised October 2019
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Experience Affidavit YOUR CONTACT INFORMATION Mailing Address (Street, (Washington)

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Completed 26 February 2022

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