Skip to main content
Bellevue home
  • Bellevue Home
  • City Government
    • Boards, Commissions and Committees
    • City Code, Resolutions and Ordinances
    • City Council
    • Communications
    • Departments
    • East Bellevue Community Council
    • Hot Topics and Initiatives
    • Public Records Requests
    • Sister Cities
  • Departments
    • City Attorney's Office
    • City Clerk's Office
    • City Manager's Office
    • Communications
    • Community Development
    • Development Services
    • Emergency Management
    • Finance & Asset Management
    • Fire
    • Human Resources
    • Information Technology
    • Parks & Community Services
    • Police
    • Transportation
    • Utilities
  • Discover Bellevue
    • About Us
    • Bellevue Television
    • City News
    • Things to Do
    • Arts in Bellevue
    • Parks and Trails
    • Economic Development
  • Doing Business
    • Building and Zoning
    • Doing Business in Bellevue
    • Doing Business with Bellevue
  • Public Safety
    • Police
    • Fire
    • Emergencies and Extreme Weather
    • Emergency Preparedness
    • Municipal Court
    • Neighborhood Traffic Safety
    • Probation
    • Public Defenders
  • Resident Resources
    • ADA and Language Access Resources
    • Customer Assistance
    • Conflict Assistance
    • Diversity Advantage
    • Neighborhoods
    • Newcomers Guide
    • Permits, Parking and Utilities
    • Volunteering
    • Local Service Agencies
City of Bellevue, WA City Manager's Office
English Español 简体中文 繁體中文 日本語 한국어 Pусский Tiếng Việt

Indigency Screening Form

Breadcrumb

  1. Home
  2. City Government
  3. Departments
  4. City Manager's Office
  5. Indigency Screening Form
bellevue home

How may I help you?

This is an artificial-intelligence (AI) chatbot designed to provide general information about various city topics. If you are having an emergency of any kind, please call 911 immediately. The chatbot is still learning about all of our services and may occasionally provide an incorrect answer.

Give Feedback
  • Copied to clipboard

    City Manager's Office

    • City Manager's Office Staff
    • Communications
      • Communications Team
      • City News
      • Bellevue Television
      • For the Media
      • Hot Topics and Initiatives
      • It's Your City
      • Social Media
      • Emergencies and Extreme Weather
    • Office of Housing
    • Diversity Advantage Initiative
      • Diversity Advantage Team
      • Diversity Advantage Plan Update
      • Cross-Cultural Center Without Walls
      • Events
      • Bellevue Diversity Advisory Network
      • Bellevue Centers Communities of Color
      • Hate Has No Home Here
      • ADA/Title VI Resources
    • Immigrant and Refugee Resources
    • Management Fellowship
    • Mission and Core Values

    You have the right to have an attorney represent you on any criminal charge. If you cannot afford an attorney, you may qualify for the appointment of a public defender. To find out if you qualify, you must interview by phone, online or in-person at the King County District Court - Bellevue Division. 

    Complete and submit this online form to see if you qualify for a public defender. A screener will contact you with the results. For any questions regarding the process, please contact the screener at publicdefense@bellevuewa.gov or 425-647-2412.

    Contact Information

    Name
    Address
    An email address is required for this form of screening. A public defense screener must be able to contact you to process your application and give you details about your public defender, if appointed.

    Public Assistance

    Assistance Received
    Please Describe

    Financial Information

    Do you work or have a job?

    Job Section

    Do you have a spouse or state registered domestic partner who lives with you?
    Does she/he work?
    Do you and/or your spouse or state registered domestic partner receive unemployment, Social Security, a pension, or workers’ compensation?
    Do you receive money from any other source?
    Do you own a home?
    Do you own a vehicle(s)?
    Please provide the following for all your vehicles
    Other than routine living expenses such as rent, utilities, food, etc., do you have other Monthly expenses such as child support payments, court-ordered fines or medical bills, etc.?
    Please identify each expense and how much you pay per month:
    Do you have money available to hire a private attorney?
    Do you own any jewelry or other items of value?

    Confirmation

    Please read and agree to the following before submitting this indigency screening form:

    • I understand the court may ask for verification of the information provided above.
    • I agree to immediately report any change in my financial status to the court.

    “I certify under penalty of perjury under Washington State law that the above is true and correct. (Perjury is a criminal offense-see Chapter 9A.72 RCW)”

    CAPTCHA

    Reasonable Accommodation

    For alternate formats, interpreters, or reasonable modification requests please phone at least 48 hours in advance 425-452-6800 (voice) or email servicefirst@bellevuewa.gov. For complaints regarding modifications, contact the City of Bellevue ADA, Title VI, and Equal Opportunity Officer at ADATitleVI@bellevuewa.gov.

    City of Bellevue sealCity of Bellevue, WA

    • 450 110th Avenue NE
    • Bellevue, WA 98004
    • Directions to City Hall
    • 425-452-6800
    • servicefirst@bellevuewa.gov
    • Contact Us / City Directory
    • Monday - Friday 8 a.m. - 4 p.m.

    Footer Menu Contacts

    • MyBellevue Customer Assistance
    • Careers
    • ADA/Title VI Notices

    Languages

    • English
    • Español
    • 简体中文
    • 繁體中文
    • 日本語
    • 한국어
    • Pусский
    • Tiếng Việt

    Request a Translation

    • Request a Translation
    • اطلب ترجمة
    • 申请翻译
    • 要求翻譯
    • अनुवाद का अनुरोध करें
    • 翻訳をリクエストする
    • 번역 요청
    • درخواست ترجمه
    • ਅਨੁਵਾਦ ਦੀ ਬੇਨਤੀ ਕਰੋ
    • Запрос на перевод
    • Solicitud de traducción
    • అనువాదం అడగండి
    • ترجمےکے لئے ایک درخواست
    • Yêu cầu bản dịch
    • ትርጉም መጠየቅ

    Social Media

    © 2024 City of Bellevue | All Rights Reserved. | ADA/Title VI Notices | Terms of Use | Privacy Policy | Site Map