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Online Public Defense Screening Form
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This form has been modified since it was saved. Please review all fields before submitting.
Next Court Date
Telephone # ex: 123-456-7890
Place an X next to any of the following assistance you receive:
DSHS Client ID
Pregnant Women Benefits
Poverty Veterans Benefits
Refugee Settlement Benefits
Aged, Blind, Disabled Benefits
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?
If so, take home pay: $
Do you have a spouse/partner who lives with you?
Does your spouse/partner work?
If so, take home pay: $
Do you and/or your spouse/partner receive unemployment, social security, a pension or workers compenstation?
If so, which one?
Do you have children residing with you?
If so, how many?
Do you own a home?
If so, value $
Amount owed $
Including yourself, how many people in your household do you support?
Do you own any vehicle(s)?
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?
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
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.
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
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