Declaration Of Indigency
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Declaration Of Indigency Form. This is a Washington form and can be use in Chelan Local County.
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Tags: Declaration Of Indigency, Washington Local County, Chelan
IN THE SUPERIOR COURT OF THE STATE OF WASHINGTON
IN AND FOR THE COUNTY OF CHELAN
State of Washington,
Plaintiff,
v.
,
Defendant.
STATE OF WASHINGTON
COUNTY OF CHELAN
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DECLARATION OF INDIGENCY
NO.:
ss
I,
, the above named defendant, do want a
lawyer to represent me in the case. I am without income or assets with which to retain an
attorney.
1.
GENERAL INFORMATION
(a)
Name:
(b)
Address:
(c)
Telephone number:
(d)
Marital status: [ ] Single [ ] Married [ ] Separated
Spouses Name:
Spouses Address:
(e)
Number of dependents:
Age of dependents:
Are you presently employed: [ ] Yes [ ] No
Occupation:
Length of employment:
(f)
Name and address of employer:
Prior employer:
(g)
Is spouse employed? [ ] Yes [ ] No
Occupation:
Length of employment:
Name of spouse’s employer:
2.
INCOME
(a)
Gross monthly income (mine)
(b)
Gross monthly income (spouse)
(c)
Other income
$
$
$
ASSETS
(a)
Cash on hand
$
3.
2001 © American LegalNet, Inc.
(b)
(c)
(d)
(e)
(f)
4.
5.
Savings account
Checking account
Home (cash value less amount owing)
Vehicles (cash value less amount owing)
Make and year:
Other assets and property
MONTHLY LIVING EXPENSES
(a)
Rent or mortgage
(b)
Food
(c)
Utilities
(d)
Transportation
(e)
Medical, dental, and insurance
(f)
Other
DEBTS
Name of Creditors:
$
$
$
$
$
$
$
$
$
$
$
AMOUNT OWED:
$
$
$
$
Should there be any change in my income or assets, I will advise the court immediately.
I have been advised that I may be required to repay all or part of the costs of court
appointed counsel.
I declare under penalty of perjury, under the laws of the State of Washington, that the
above information is true and correct.
Signature
Date signed
Place signed
2001 © American LegalNet, Inc.
