Court Use Only:
STATE OF WASHINGTON
$______ / ________
Tukwila Municipal Court
INDIGENCY SCREENING FORM
Date: ____________
CONFIDENTIAL ([Per RCW 10.101.020(3))
Name:
(LAST)___________________________________________(FIRST)_________________________________(MIDDLE INIT.)_____________
Address: _________________________________Apt/Unit______ City, _________________ Zip, __________
Phone(s): ______________________/____________________ Citation/Case Number: __________________
1. Place an “x” next to any of the following types of financial assistance you receive:
_____Welfare
_____Poverty Related Veterans’ Benefits
_____Food Stamps
_____Temporary Assistance for Needy Families
_____SSI
_____Disability Lifeline Benefits
_____Medicaid
_____Refugee Settlement Benefits
_____General Assistance
_____Other- please describe: _______________
(If you marked an “X” by any of the above, please stop here and sign at #14 on back page.)
Court Verification Only: _____________________________________________________________________
2. Do you work or have a job? ______Yes ______No
If yes, please complete the following:
Place of employment: ____________________________________
How long have you worked at this location: ____________________
Your monthly take-home pay (after taxes): $_______________
3. Do you receive State Unemployment Benefits?
______Yes ______No
Your monthly take-home pay (after taxes): $_______________
4. Are you currently a student or enrolled in school?
______Yes ______No
5. Do you have a spouse or state registered domestic partner who lives with you? ______Yes ______No
If yes, and are he/she is employed please complete the following:
Place of employment: ____________________________________
Your spouse’s or partner’s monthly take-home (after taxes) pay: $_______________
6. Does your spouse or state registered domestic partner receive Unemployment, Social Security, a pension,
or workers’ compensation? ______Yes ______No
If yes, please explain: _________________________
7. Do you have any other source of income? If yes, please complete the following:
Type of Income: ________________________________
Amount of Income: $_______________
Total Income: $_______________
*PLEASE COMPLETE BACK OF APPLICATION*
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