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City of Auburn

humanresources@auburnwa.gov

253-931-3040

Auburn Municipal Court

Public Defender Screening Form

CONFIDENTIAL [Per RCW 10.101.020(3)]

Full Address

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?

Please read and sign the following:

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.)

Choose how to sign

----------- FOR COURT USE ONLY -----------

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: ______________________

Judge/Screener: ________________________