subject_line

Indigency Screening Form

INDIGENCY SCREENING FORM CONFIDENTIAL (RCW 10.101.020(3))

STATE OF WASHINGTON v.

Thurston County Cause No.

1. Name and Address

Name and Address *

2. Benefits Information

Do you receive any of the following benefits?

Welfare	Food Stamps
SSI	Medicaid
Pregnant Women Assistance Benefits	Poverty Related Veterans’ Benefits
Temporary Assistance for Needy Families	Refugee Settlement Benefits
Aged, Blind or Disabled Assistance Program

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? *

Yes

No

How many?

Age(s)

4. Employment Information

Are you employed? *

Yes

No

Employer's Name

Employer's Phone Number

5. Private attorney option

Do you have money to hire a private attorney? *

Yes

No

6. Income

Monthly wages or salary *

Spouse's wages or salary *

Other Income *

Total Net Monthly Income

0.00

7. Monthly Expenses & Debt

Rent/House payment *

Food *

Utilities *

Transportation *

Insurance *

Medical and Dental *

Child Care *

Other *

List Creditors To Whom You Owe Debt

Creditor 1 Name

Amount 1

Creditor 2 Name

Amount 2

Creditor 3 Name

Amount 3

Creditor 4 Name

Amount 4

Total Monthly Expenses & Debt

0.00

8. What assets do you own?

Money in checking account(s) *

Money in savings account(s) *

Value of vehicles, boats, RV, etc. *

Value of stocks and bonds *

Cash *

Home Equity *

Other *

Total Assets

0.00

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.)

Date *

Olympia, Washington

Signature *

clear