Indigency Screening Form - Washington Tukwila Municipal Court Page 2
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28. Do you have children living with you? ______Yes ______ No
If yes, how many? _________________
9. How many people in your household, do you support with your income?
______
10. Do you own a home? ______Yes ______No
Do you rent a home? ______Yes ______No
Monthly payment: $_______________
If yes to own, please complete the following:
Year your home was purchased: _______________
Value: $___________
Last time home was refinanced: _______________
Amount owed: $___________
11. Do you own a vehicle? ______Yes ______No
If yes, please complete the following:
Make/Model of Vehicle ________________
Vehicle year: _______________________
Monthly payment: $_______________
12. Other than your routine monthly expenses, do you have other mandatory expenses?
Example: child support payments, court-ordered fines or medical bills, etc.
If yes, please complete the following:
Mandatory expenses – Monthly payment: $_______________
13. Do you have a bank account? ______Yes ______No If yes, please complete the following:
Checking/Savings: $_______________
Stocks, bonds or other investments? $_______________
14. READ CAREFULLY:
I give my permission for the court or designated agency to verify this information and I authorize all persons
listed above to release my financial information to the Tukwila Municipal Court, and I agree to hold them
harmless for such release. I also 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)
___________________________________________________________
Signature
Date
PLEASE SIGN-IN WHEN COMPLETED
FOR COURT USE ONLY - DETERMINATION OF INDIGENCY
_____ Eligible for a public defender
_____ Re-screen in future regarding change of income (e.g. defendant works seasonally)
_____ Not eligible for a public defender
__________________________
__________________________
_______________
JUDGE or JUDGE’S DESIGNEE
Title
Date
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