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Online Public Defense Screening Form

  1. Place an X next to any of the following assistance you receive:

  2. Welfare

  3. Food Stamps

  4. SSI

  5. Medicaid

  6. Pregnant Women Benefits

  7. Poverty Veterans Benefits

  8. TANF

  9. Refugee Settlement Benefits

  10. Aged, Blind, Disabled Benefits

  11. 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.

  12. Do you work or have a job?*

  13. Do you have a spouse/partner who lives with you?*

  14. Does your spouse/partner work?*

  15. Do you and/or your spouse/partner receive unemployment, social security, a pension or workers compenstation?*

  16. Do you have children residing with you?*

  17. Do you own a home?*

  18. Do you own any vehicle(s)?*

  19. Do you receive any tribal per capita?*

  20. Do you have money available to hire a private attorney*

  21. 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.

  22. FOR COURT USE ONLY - DO NOT USE- DETERMINATION OF INDIGENCY

  23. Eligible for public defender at no expense: Y or N

  24. Eligible for a public defender but must contribute: $

  25. Re-screen in future regarding change of income: Y or N

  26. Not eligible for public defender: Y

  27. Signature/ Date

  28. Leave This Blank:

  29. This field is not part of the form submission.