• Indigency Screening Form

    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)”