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Online Public Defense Screening Form
Sign in to Save Progress
This form has been modified since it was saved. Please review all fields before submitting.
Case #
*
Next Court Date
*
First Name
Last Name
Address1
City
State
Zip
Email
Telephone # ex: 123-456-7890
*
Place an X next to any of the following assistance you receive:
DSHS Client ID
Welfare
Yes
Food Stamps
Yes
SSI
Yes
Medicaid
Yes
Pregnant Women Benefits
Yes
Poverty Veterans Benefits
Yes
TANF
Yes
Refugee Settlement Benefits
Yes
Aged, Blind, Disabled Benefits
Yes
Other- please describe
If you marked any of the boxes above, recipients of public assistance are presumed indigent and may be found able to contribute to the cost of their defense. Please proceed to upload any documents and submit form.
Do you work or have a job?
*
Yes
No
If so, take home pay: $
Employer name
Do you have a spouse/partner who lives with you?
*
Yes
No
Does your spouse/partner work?
*
Yes
No
If so, take home pay: $
Do you and/or your spouse/partner receive unemployment, social security, a pension or workers compenstation?
*
Yes
No
If so, which one?
Amount $
Do you have children residing with you?
*
Yes
No
If so, how many?
Do you own a home?
*
Yes
No
If so, value $
Amount owed $
Including yourself, how many people in your household do you support?
Do you own any vehicle(s)?
*
Yes
No
If so, make/model
Amount owed: $
How much money do you have in checking/saving account(s)? $
How much money to you have in stocks, bonds or other investments? $
Do you receive any tribal per capita?
*
Yes
No
Average amount per month? $
How much are your routine living expenses (rent, food, utilities, transportation, phone) ? $
Other than routine living expenses, do you have other expenses such as child support, court ordered fines, medical bills, etc? If so, describe:
Do you have money available to hire a private attorney
*
Yes
No
Documents
Please read and sign the following: I understand the court may require verification of the information provided above. I agree to immediately report any change in my financial status to the court. I certify under perjury under Washington State law that the above is true and correct.
Electronic signature
*
Date/Time
*
Date/Time
Date/Time
FOR COURT USE ONLY - DO NOT USE- DETERMINATION OF INDIGENCY
Eligible for public defender at no expense: Y or N
Eligible for a public defender but must contribute: $
Re-screen in future regarding change of income: Y or N
Not eligible for public defender: Y
Signature/ Date
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