King County District Court
Public Defender Screening Form
CONFIDENTIAL [Per RCW 10.101.020(3)]
Please mark any of the following types of assistance you receive:
Recipients of public assistance are presumed indigent, but may be found able to contribute to the costs of their defense under RCW 10.101.010. Stave v. Hecht, 173 Wash. 2d 92 (2011).
Do you work or have a job?
Take-home amount listed is for what time period?
Do you have a spouse or state registered domestic partner who lives with you?
Does he/she work?
Do you and/or your spouse or state registered domestic partner receive unemployment, Social Security, a pension, or workers’ compensation?
Do you receive money from any other source?
Do you have children residing with you?
Do you own a home?
Do you own a vehicle(s)?
Do you have money available to hire a private attorney?
I understand 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 criminal offense-see Chapter 9A.72 RCW.)
DETERMINATION OF INDIGENCY
_____ Eligible for a public defender at no expense
_____ Eligible for a public defender but must contribute $_______
_____ Re-screen in future regarding change of income (e.g. defendant works seasonally)
_____ Not eligible for a public defender
_____ Incomplete: ______________________