(Copy Receipt) (Clerk's Date Stamp) SUPERIOR COURT OF WASHINGTON COUNTY OF SPOKANE Petitioner: _________________________ vs. Respondent: _______________________ CASE NO: _______________________ MOTION AND DECLARATION FOR ASSIGNMENT OF LAWYER (MTAF) I. MOTION 1.1 1.2 1.3 I, the undersigned: Petitioner Respondent in this matter moved the court for an order appointing a lawyer to represent me at public expense; The following declaration is made in support of this motion. I UNDERSTAND THAT ANY STATEMENT THAT I MAKE IN THE FOLLOWING DECLARATION MAY BE USED AGAINST ME. II. DECLARATION I declare under penalty of perjury under the laws of the State of Washington that the following is true and correct. 2.1 2.2 2.3 I am the Respondent the Petitioner I this matter; I want a lawyer to represent me in this matter; I am financially unable to obtain the services of a lawyer without causing substantial hardship to myself of my family; PAGE 1 OF 3 MOTION AND DECLARATION FOR ASSIGNMENT OF LAWYER (Rev: 06/2001) American LegalNet, Inc. www.FormsWorkFlow.com 2.4 I declare under penalty of perjury that the following information is true and intended to be relied upon by the court and other persons or agencies in determining my eligibility for legal services to be furnished me at public expense. III. FINANCIAL STATEMENT 3.1 General Information ________________________ ________________________ ________________________ (c) Social Security No.: (d) Telephone No.: (e) Date of Birth: _______________________ _______________________ _______________________ (a) Name: (b) Address: City/State (f) Marital Status: Married Divorced Separated Single (g) Persons whom you financially support: List children's names, ages, and if different, address: Spouse Children Other (h) Are you presently employed? No Yes Length of employment: ________ Occupation: ________________ (i) Is spouse employed? Yes No Occupation: _______________ Name and address of employer, or if currently unemployed, prior employer: _________________________________________________ Name and address of employer: ________________________________________________ MOTION AND DECLARATION FOR ASSIGNMENT OF LAWYER (Rev: 06/2001) PAGE 2 OF 3 American LegalNet, Inc. www.FormsWorkFlow.com 3.2 INCOME AND ASSETS (a) Gross monthly __________________ income 3.3 EXPENSES AND DEBTS (a) Monthly living expenses ______________ (itemize) ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ (personal) (b) Gross monthly ___________________ Rent or Mortgage income (spouse) Food (c) Other income (d) Cash: Savings account Checking account On hand (e) Home-cash value less amount owing (f) Auto-cash value less amount owing (list make & year) ___________________ ___________________ (g) Furniture (approximate value) (h) Notes, mortgages, trusts, deeds (i) Stocks, bonds (approximate value) (j) Other assets and property (k) Any indebtedness owed to you ___________________ Utilities Transportation ___________________ Installment payments ___________________ Medical & dental ___________________ Insurance ___________________ Other ___________________ (b) Debts: Name/creditor _______________________ _______________________ Amount owed ______________ ______________ __________________ __________________ __________________ __________________ __________________ Signature Date _____________________ MOTION AND DECLARATION FOR ASSIGNMENT OF LAWYER (Rev: 06/2001) PAGE 3 OF 3 American LegalNet, Inc. www.FormsWorkFlow.com