Indigency Screening Form

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Fife Municipal Court
3737 Pacific Highway E.
Fife, WA 98424
253-922-6635
$10 APPLICATION FEE RESERVED
INDIGENCY SCREENING FORM
CONFIDENTIAL
)]
[Per RCW 10.101.020(3
Name_______________________________________________________________________________
Address_____________________________________________Phone#__________________________
City_______________State__________Zip__________Case # / Court date _______________________
1. Place an “x” next to any of the following types of assistance you receive:
_____Welfare
_____Poverty Related Veterans’ Benefits
_____Food Stamps
_____Temporary Assistance for Needy Families
_____SSI
_____Refugee Settlement Benefits
_____Medicaid
_____Disability Lifeline Benefits
_____Other – Please Describe_______________________________________
If social security is checked, please check reason: ___Disability ___Retirement ___Military ___Widower
___Foster child ___ Other – Please explain ________________________________________________ .
Per RCW 10.101.010 Indigency has been determined; the following information will be used to
determine if “able to contribute” applies.
2. Do you have a job? ____yes ____no. If yes, what is your take-home pay: $___________
Occupation: ______________ Employer’s name & phone #:_____________________________
3. Do you receive a stipend?
____yes ____no.
If yes, how much: $___________
4. Do you have a spouse or state registered domestic partner who lives with you? ___yes ___no.
Does she/he work? ____yes ____no. If yes, take-home pay: $________________
Employer’s name: __________________________________________________
5. Do you and/or your spouse or state registered domestic partner receive unemployment,
social security, a pension or workers’ compensation? ____ yes ____no. (If yes, circle those that apply) Any type of
public assistance? ____ yes ____ no. If yes, amount? $ ___________________.
Who in the family receives it? ___________________________________ Amount: $__________
6. Do you receive money from any other source? ____ yes ____no. If yes, how much?
(This includes any
contribution received from any family member or other person living in the same residence as you helping to defray
your basic living costs.)
$_____________
7. Do you and/or your spouse or partner have children residing with you? ____ yes ____no.
If no, do you pay child
support? ____ yes ____ no. If yes how much? $___________
8. Counting yourself; how many people in your household do you support? ___________
9. Do you own a home? ____yes ____no. If yes, value: $________________ Amount owed: $__________________
County: ________________________ Address: _____________________________________

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