Indigency Screening Form

INDIGENCY SCREENING FORM                                                            CONFIDENTIAL (RCW 10.101.020(3))

1. Name and Address
2. Benefits Information
Do you receive any of the following benefits?
If you receive any of the above benefits, skip the rest of the questions and sign the bottom.
3. Support Information
Do you provide support to people who live with you? *
4. Employment Information
Are you employed? *
5. Private attorney option
Do you have money to hire a private attorney? *
6.  Income
Total Net Monthly Income
7.  Monthly Expenses & Debt
List Creditors To Whom You Owe Debt
Total Monthly Expenses & Debt
8.  What assets do you own?
Total Assets
9.  Read and Sign

I understand that 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 crime.)
Olympia, Washington
Signature *
Secured by Formsite