SUPERIOR COURT OF THE STATE OF WASHINGTON IN AND FOR THE COUNTY OF DOUGLAS State of Washington, ) ) DECLARATION OF INDIGENCY Plaintiff, ) ) No.: _________________________ ) ) _____________________, ) ) Defendant. ) __________________________________________________________________ STATE OF WASHINGTON COUNTY OF DOUGLAS ) ) ss ) I, ________________________________, the above named defendant, do want a lawyer to represent me in this case. I am without income or assets with which to retain an attorney. 1. GENERAL INFORMATION (a) (b) (c) (d) Name: __________________________________________________ Address: ________________________________________________ Telephone number: ________________________________________ Marital status: [ ] Single [ ] Married [ ] Separated Spouse's Name: __________________________________________ Spouses Address: _________________________________________ (e) Number of dependents: ____________________________________ Age of dependents: _______________________________________ Are you presently employed: [ ] Yes [ ] No 2001 © American LegalNet, Inc. 2 Length of employment: _________ Occupation: ________________ (f) (g) Name and address of employer: ______________________________ Prior employer: ___________________________________________ Is spouse employed? [ ] Yes [ ] No Length of employment: ________ Occupation: _________________ Name of spouse's employer: ________________________________ 2. INCOME (a) Gross monthly income (mine) (b) Gross monthly income (spouse) (c) Other income $ _____________ $ _____________ $ _____________ 3. ASSETS (a) Cash on hand $ _____________ (b) Savings account $ _____________ (c ) Checking account $ _____________ (d) Home (cash value less amount owing) $ _____________ (e) Vehicles (cash value less amount owing)$ _____________ Make and year: ___________________ (f) 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: $ _____________ $ _____________ $ _____________ $ _____________ $ _____________ $ _____________ $ _____________ $ _____________ $ _____________ $ _____________ 4. 5. Should there be any change in my income or assets, I will advise the court immediately. 2001 © American LegalNet, Inc. 3 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.