"To the People of the State of Washington

Greeting:

I, the undersigned Governor of the State of Washington, by virtue of the power vested in my office by the constitution and laws of the State of Washington, do by these presents restore to  . . . . . . . . . his or her civil rights forfeited by him (or her) by reason of his (or her) conviction of the crime of  . . . . . . . . . (naming it) in the Superior Court for the County of  . . . . . . . . ., on to-wit: The  . . . . day of  . . . . . ., (year) . . . .

Dated the  . . . . day of  . . . . . ., (year) . . . .

(Signed)  . . . . . . . . . . . . . . . . . . . . . . .