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Financial Declaration Form

  1. THIS FINANCIAL DECLARATION FORM IS CONFIDENTIAL PER RCW 10.101.020(3)

  2. 1. Have you ever served in the US Military? *

  3. Are you able to provide a DD214?

  4. 2. Which types of assistance, if any, do you currently receive?*

    Check all that apply:

  5. 3. Are you employed? *

  6. 4. Do you have a spouse or state registered domestic partner who lives with you? *

  7. Is she/he employed?

  8. 5. Do you and/or your spouse or state registered domestic partner receive unemployment, social security, a pension, or worker's compensation?*

  9. If yes, which benefit?

  10. 6. Do you receive money from another source?*

  11. 8. Do you own a home? *

  12. 9. Do you own any vehicles?*

  13. 12. Please list your monthly living expenses below:

  14. 13. Have you ever been involuntarily committed to a public mental health facility?*

  15. PLEASE READ AND ACKNOWLEDGE 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 Pierce County District Court. I certify under penalty of perjury under Washington State law that the above is true and correct. Perjury is a criminal offense (see chapter 9A.72 RCW).

  16. Leave This Blank:

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