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Indigency Screening Form

  1. This form is confidential per RCW 10.101.020(3).

  2. Please input an email address where you may receive court documents.

  3. Have you ever served in the US Military?

  4. Are you able to provide a DD214?

  5. Please check any of the following types of assistance you receive:

  6. Do you work or have a job?

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

  8. Do they work?

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

  10. If yes, which benefit?

  11. Do you receive any money from another source?

  12. Do you own a home?

  13. Do you own a vehicle(s)?

  14. Please fill out your monthly living expenses in the following categories:

  15. Have you ever been involuntarily committed to a public mental health facility?

  16. Please read and agree to the following by clicking the 'Submit' button.

    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 court. by clicking 'Submit,' 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.

  17. Leave This Blank:

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