2. Case # *
3. Next Court Date*
5. First Name
6. Last Name
8. Address1
10. City
11. State
12. Zip
14. Email
15. Telephone # ex: 123-456-7890*
17. Place an X next to any of the following assistance you receive:
19. DSHS Client ID
21. Welfare

    1. Yes
22. Food Stamps

    1. Yes
23. SSI

    1. Yes
24. Medicaid

    1. Yes
26. Pregnant Women Benefits

    1. Yes
27. Poverty Veterans Benefits

    1. Yes
28. TANF

    1. Yes
29. Refugee Settlement Benefits

    1. Yes
31. Aged, Blind, Disabled Benefits

    1. Yes
32. Other- please describe
34. 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.
36. Do you work or have a job?*

    1. Yes
    2. No
37. If so, take home pay: $
38. Employer name
40. Do you have a spouse/partner who lives with you?*

    1. Yes
    2. No
41. Does your spouse/partner work?*

    1. Yes
    2. No
43. If so, take home pay: $
45. Do you and/or your spouse/partner receive unemployment, social security, a pension or workers compenstation?*

    1. Yes
    2. No
47. If so, which one?
48. Amount $
50. Do you have children residing with you?*

    1. Yes
    2. No
51. If so, how many?
53. Do you own a home?*

    1. Yes
    2. No
54. If so, value $
55. Amount owed $
57. Including yourself, how many people in your household do you support?
59. Do you own any vehicle(s)?*

    1. Yes
    2. No
60. If so, make/model
61. Amount owed: $
63. How much money do you have in checking/saving account(s)? $
65. How much money to you have in stocks, bonds or other investments? $
67. Do you receive any tribal per capita?*

    1. Yes
    2. No
68. Average amount per month? $
70. How much are your routine living expenses (rent, food, utilities, transportation, phone) ? $
72. Other than routine living expenses, do you have other expenses such as child support, court ordered fines, medical bills, etc? If so, describe:
74. Do you have money available to hire a private attorney*

    1. Yes
    2. No
76. Documents
78. 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.
80. Electronic signature*
81. Date/Time*
    Date/Time

    Date/Time
85. FOR COURT USE ONLY - DO NOT USE- DETERMINATION OF INDIGENCY
87. Eligible for public defender at no expense: Y or N
88. Eligible for a public defender but must contribute: $
90. Re-screen in future regarding change of income: Y or N
91. Not eligible for public defender: Y
93. Signature/ Date
Leave This Blank:


95. 1. Receive an email copy of this form.
96. Email address

    This field is not part of the form submission.

97. Submit

* indicates a required field