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