HomeMy WebLinkAbout2020INDIGENCY FORMAPPLICATION FOR PUBLIC DEFENDER ( ) Dist Crt !fi Sup crt
YOURNAME: _- : CASENUMBERT---II-_J
PRESUMPTIVE ELIGIBILITY:
DEFENDANT RECEIVES- AFDC GAU FOOD STAMPS SSI VA MEDICAID WIC MED CORP ADATSA
OTHER (Specify)
MONTHLY INCOME:
Present Employer (Name, Address & Phone #)How Long Employed Hours workcd per ueek
Spouse's Employer (Name, Address & Phone #)Hor Long Employed Hours worked per rveek
$
s
$
$
$
SUPPORT OBLIGATIONS:
TOTAL NUMBER OF DEPENDENTS (Include Yoursel|:
TOTAL BASIC LIVING EXPENSE$
COURT IMPOSED OBLIGATIONS (Speciry Monthly Amount)
BAIL/BOND PAID (This Offense)
OTHER (Unusual) EXPENSES (Speci&)
$
$
$
(Medical Bills, Child Support,Prior Attorney Fees, Past Due Utiiity, Rent, IRS Payments, Union Dues, Collection Agency, etc)
TOTAL MONTHLY EXPENSES $
TOTAL INCOME MINUS TOTAL EXPf,NSES EQUALS DISPOSABLf, NET MONTHLY INCOME $
LIQUID ASSETS:
CASH (On Hand/On Books, Savings, Checking, Bank Accounts)
STOCKS, BONDS, CERTIFICATES OF DEPOSIT
EQUITY IN REAL ESTATE
EQUITY IN MOTOR VEHICLE NOT REQUIRED FOR WORK
EQUITY IN ADDITIONAL VEHICLES
PERSONAL PROPERTY (Boats, stereo, vCR, Jewelry, Guns, etc.)
AFFIDAVIT AND NOTIFICATION
I,
TOTAL LIQUID ASSETS $
(print name), do hereby certiry and declare under penalty ofperjury under the Laws ofthe
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$
$
$
$
$
State ofWashington, that the foregoing is true and corrcct (RCW 9A.72.085). By my signaturc below,
all information provided hcrc. Vcrification may include a crcdit rcport. I fudler swear to immediately
court. I understand ifbail is imposed in this matter or if my financial condition changes, I may request a re-detcrmination.
SIGNED DATE
I authorize the court or its designee to veriry
repon any change in financial status to the
COURT USE ONLY
DETERMINATION OF INDIGENCY:
A. DISPOSABLE NET MONTHLY INCOME $
B. TOTAL LIQUID ASSETS $-
C. TOTALAVAILABLEFUNL
( ) Indigent ( ) Indigent and able to contribute leYel at E 1 2 3
( ) Indig€nt contingent on proof of income and/or screening fee ( ) Not Eligible ( ) In custody
Date:
Judge or Designee
APPLICANT'S MONTHLY TAKE HOME PAY (After Ta\es)
SPOUSE'S MONTHLY TAKE HOME PAY (After Taxes)
NON-POVERTY BASED ASSISTANCE (Unemployment, Social Security, L&1, etc.)
OTHER INCOME (Child Support, Spousal Maintenance, Rental Income, etc.)
TOTAL MONTHLY INCOME:
MONTHLY EXPENSES (For Applicant & Depondents):
BASIC MONTHLY LIVING EXPENSES:
-
RENTMORTGAGE PHONE
-
ELECTRICITY
-WATEfuSEWER
LIFE/HOUSE INSURANCE TRANSPORTATION TO WORK
CARPAYMENT CARINSURANCE GAS FOOD