Indigency Screening Form

Bomb cyclone storm impacts

A bomb cyclone windstorm lashed Bellevue the night of Tuesday, Nov. 19, bringing down trees throughout the city and leaving hundreds of thousands without power. Most city facilities, including City Hall, had power Wednesday, damages from the storm continue to impact Bellevue. Updates about the city's response will be posted at Bomb Cyclone Storm.

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

First

Last

Date of Birth

Address

Address 2

City/Town

State

ZIP/Postal Code

Telephone

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.

Case Number

Charges

Financial Information

Do you work or have a job?

Yes

Employer’s Name

Employer’s Phone Number

Take Home Pay

Do you have a spouse or state registered domestic partner who lives with you?

Yes

Does she/he work?

Yes

Spouse or Partners Take Home Pay

Spouse or Partner's Employer’s name:

Do you and/or your spouse or state registered domestic partner receive unemployment, Social Security, a pension, or workers’ compensation?

Yes

If so, which one?

Amount Received

Do you receive money from any other source?

Yes

Amount from other sources

How many children do you have residing with you?

Including yourself, how many people in your household do you support?

Do you own a home?

Yes

How much equity do you have in it?

Do you own a vehicle(s)?

Yes

Please provide the following for all your vehicles

Please provide the following for all your vehicles
Vehicle Model Vehicle Year Vehicle Equity

How much money do you have in checking/saving account(s)?

How much money do you have in stocks, bonds, trusts or other investments?

How much are your routine monthly living expenses (rent, food, utilities, transportation)?

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.?

Yes

Please identify each expense and how much you pay per month:

Please identify each expense and how much you pay per month:
Expense Cost Per Month
Expense Cost Per Month

Do you have money available to hire a private attorney?

Yes

Do you own any jewelry or other items of value?

Yes

What is the 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)”

I Agree

First and Last Name

CAPTCHA

Bomb cyclone storm impacts

Indigency Screening Form

Contact Information

Public Assistance

Financial Information

Job Section

Confirmation