Financial Declaration Form

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

4. Legal First Name:*

5. Legal Middle Name:

6. Legal Last Name:*

8. Address:*

9. Apt/Suite/Unit:

11. City:*

12. State:

13. Zip:

15. Cell Number:*

16. Email Address (where you may receive court documents):

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

    1. Yes
    2. No

21. Are you able to provide a DD214?

    1. Yes
    2. No

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

    Check all that apply:

    1. ABD - Aged, Blind or Disabled Assistance Program
    2. Basic Food Program/Food Stamps
    3. HEN - Housing & Essential Needs Program
    4. MCS - Medical Care Services
    5. Poverty-related Veterans Benefits
    6. PWA - Pregnant Women Assistance Benefits
    7. Refugee & Immigrant Assistance

    1. SFA - State Family Assistance
    2. SSI - Supplemental Security Income
    3. TANF - Temporary Assistance for Needy Families
    4. WIC - Women, Infants & Children Nutrition Program
    5. Other - Please Describe
    6. NONE - I do not receive assistance
27. List other assistance you currently receive:

31. 3. Are you employed? *

    1. Yes
    2. No

32. Employer/Company Name:

33. Monthly take-home pay:

35. Occupation:

36. Work Phone:

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

    1. Yes
    2. No

41. Is she/he employed?

    1. Yes
    2. No

42. Monthly take-home pay:

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

    1. Yes
    2. No

45. If yes, which benefit?

    1. Unemployment
    2. Social Security
    3. A Pension
    4. Worker's Compensation

46. Total per month:

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

    1. Yes
    2. No

49. If yes, list source:

50. Amount received:

52. 7. Including yourself, how many legal dependents do you support?*
    -- Select One --1234567+

54. 8. Do you own a home? *

    1. Yes
    2. No

55. Current value of home:

56. Amount owed on home:

58. 9. Do you own any vehicles?*

    1. Yes
    2. No

59. Current value of vehicles:

60. Amount owed:

62. 10. How much money do you have in checking/saving account(s)?*

63. 11. How much money do you have in stocks, bonds, and/or other investments?*

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

69. Rent/Mortgage:

70. Utilities:

71. Food:

72. Transportation:

74. Child Support You Paid:

75. Healthcare:

76. Phone/Cable/Internet:

77. Loan Payments:

79. Other - Please describe:

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

    1. Yes
    2. No

87. 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).

    1. I acknowledge that I have read and agree to the above language. By "checking" this box, I am electronically signing this document.
Leave This Blank:


89. 1. Receive an email copy of this form.
90. Email address

    This field is not part of the form submission.

91. Submit Submit and Print

* indicates a required field