[City of Auburn] Public Defender Screening Form

King County District Court

Public Defender Screening Form

CONFIDENTIAL [Per RCW 10.101.020(3)]

First Name

Last Name

Case #

Email Address

Phone Number

If you receive other assistance, please describe it here:

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?

Yes

If so, take-home pay:

Take-home amount listed is for what time period?

1 Hour

2 Weeks

1 Month

Occupation:

Employer’s name & phone number:

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

Yes

Does he/she work?

Yes

If so, take-home pay:

Employer's name:

Do you and/or your spouse or state registered domestic partner receive unemployment, Social Security, a pension, or workers’ compensation?

Yes

If so, which one?

Amount:

Do you receive money from any other source?

Yes

If so, how much?

Do you have children residing with you?

Yes

If so, how many?

Including yourself, how many people in your household do you support?

Do you own a home?

Yes

If so, value:

Amount owed:

Do you own a vehicle(s)?

Yes

If so, year(s) and model(s) of your vehicles(s):

Amount owed:

How much money do you have in checking/saving account(s)?

How much money do you have in stocks, bonds, or other investments?

How much are your routine living expenses (rent, food, utilities, transportation)?

Other than routine living expenses such as rent, utilities, food, etc., do you have other expenses such as child support payments, court-ordered fines or medical bills, etc.? If so, describe:

Do you have money available to hire a private attorney?

Yes

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.)

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

----------- 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: ________________________