Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Determination Of Indigency Report (English) Form. This is a Washington form and can be use in Indigent Defense Statewide.
Loading PDF...
Tags: Determination Of Indigency Report (English), Washington Statewide, Indigent Defense
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
STATE OF WASHINGTON
:
Determination Of Indigency Report
Index No.
I. Identification
:
Calendar No.
County_____________________________________ Court_________________________________________________
Jurisdiction (check one) ( ) Superior ( ) District
( ) Municipal :Name of City___________________________
JUDICIAL SUBPOENA
Plaintiff(s)
Applicant's Name __________________________________________ Case Number: ____________________________
Case Type
-against:
(check the category corresponding to the most serious charge)
_____(1) Felony - Class A+
_____(5) Juvenile Felony - Class A+
: _____( 9) Dependency
_____(2) Felony - Class A
_____(6) Juvenile Felony - Class A
_____(10) Civil Commitment
_____(3) Felony - Class B or C
_____(7) Juvenile Felony - Class B or C: _____(11) Civil Contempt
_____(4) Misdemeanor
_____(8) Juvenile - Misdemeanor
_____(12) Other (specify)_______________
Defendant(s)
:
Charges___________________________________________________________________________________________
......................................................
Applicant's Address_________________________________________________________________________________
(Street)
(City)
(State)
(Zip Code)
Applicant's Telephone (___) ____ - _______ Date of Birth ____ /____ /____ Social Security # (optional) ____ /____ /____
Occupation______________________ Employer__________________________________________________________
THE PEOPLE OF THE STATE OF NEW YORK
(Name)
(Address)
(Telephone)
II. Support Obligations
TO
Total Number Dependents (include applicant in count) ____ If juvenile defendant, does he/she live with parents? (circle) Y N
If yes: Father's name _________________________ Mother's name (include maiden) ___________________________
III. Presumptive Eligibility (check all that apply)
GREETINGS:
a. __ Party is indigent because receives public assistance in form of: ( ) AFDC1 ( ) General Assistance ( ) Food Stamps
( ) Medicaid ( ) Poverty-Related V.A.2 Benefits ( ) SSI3 ( ) Refugee Resettlement Benefits ( ) Other; specify________
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
Case Number_____________________Verified? ______ Method_____________________________________________
,
the Honorable
Court
b. __ Party is indigent because committed to a public mentalat the facility.
health
located at
Verified?County of Method: __________________________________________________________________________
________
in is indigent because annual income, after taxes, is 20
, on the
day of
, 125% orat
, less of current federally established poverty level.
o'clock in the
noon, and at any recessed
c. __ Party room
or adjourned date, to testify annual evidence as a witness in this action on the part of the
$______________________ Specifyand giveincome after taxes
Verified? _______ Method: ___________________________________________________________________________
If Section III, a, b, or c applies, complete only Sections VIII, X and XI. Submit report to Court. If Section III is not
applicable, complete all remaining sections.
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
IV. Monthly Income
Verified?
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
a. Monthly take-home pay (after deductions)
$_______ Y
N
result of your failure to comply.
b. Spouse's take-home pay (enter N/A if conflict)
$_______ Y
N
c. Contribution from any person domiciled with applicant and helping defray his/her basic living costs $_______ Y
N
Witness, Honorable
, one of the Justices of the
d. Interest, dividends, or other earnings
$_______ Y
N
Court based assistance (Unemployment, of
County,
day Social Security, Workers Compensation, pension,
, 20
e. Non-povertyin
annuities) (DON'T include poverty-based assistance. See IV. a)
$_______ Y
N
f. Other income (specify) __________________________________
$_______ Y
N
Total Income type name below)
$_______
(Attorney must sign above and
V. Monthly Expenses (for applicant and dependents; average where applicable)
a. Basic Living Costs - Shelter (rent, mortgage, board)
$_______ Y
N
Utilities (heat, electricity, water); enter 0 if included in cost of shelter
$_______ Y
N
Attorney(s) for
Food
$_______ Y
N
Clothing
$_______ Y
N
Health Care
$_______ Y
N
Transportation
$_______ Y
N
Loan Payments (specify)__________________________________
$_______ Y
N
Office and P.O. Address
b. Court imposed obligations (check) ___fines ___court costs ___restitution ___support ___other
$_______ Y
N
c. Bail/bond paid or anticipated (this offense)
$_______ Y
N
d. Other expenses (specify) _____________________________________
$_______ Y
N
Telephone No.:
Total Expenses
$_______
Facsimile No.:
1
2
3
Aid to Families with Dependent Children
Veterans' Administration
Supplemental Security Income
E-Mail Address:
Mobile Tel. No.:
American LegalNet, Inc.
www.USCourtForms.com
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
VI. Total Income Part IV, minus Total Expenses Part V
Index No.
:
Disposable Net Monthly Income $________
Calendar No.
VII. Liquid Assets
Verified?
:
a. Cash, savings, bank accounts (include joint accounts)
$________
JUDICIAL SUBPOENA Y N
Plaintiff(s)
b. Stocks, bonds, certificates of deposit
$________ Y
N
-against:
c. Equity in real estate
$________ Y
N
d. Equity in motor vehicle required for employment, IF over $3,000 (list overage: value minus $3,000)
$________ Y
N
:
Make of car___________________________ Year_______________
e. Equity in additional vehicles (list total value)
$________ Y
N
:
f. Personal property (jewelry, boat, stereo, etc.)
$________ Y
N
Total Liquid Assets $________
Defendant(s)
:
.... ... .........
VIII. Affidavit. and .Notification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I, _______________________________________(print name) do hereby certify (or declare) under penalty of perjury under
the Laws of the State of Washington that the foregoing is true and correct (RCW 9A.72.085). By my signature below, I
authorize the court to verify all information provided here. I further swear to immediately report any change in financial status
THE PEOPLE OF THE STATE OF NEW YORK
to the court. I understand that if bail is imposed in this matter or if my financial condition changes I may request a
redetermination.
TO
Signed____________________________________ Date___________________
Place______________________________
IX. Determination of Indigency
GREETINGS:
a. Disposable Net Monthly Income (from Section VI)
$________
b. Total Liquid Assets (from Section VII)
+ $________ before
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend
c. Total Available Funds (a plus b)
= $________
,
the Honorable
at the
Court
d. Anticipated Cost of Counsel for Offense Type(s) at
$________
located
County of
____If (c) isroom (0) or less, ,party is INDIGENT. ____If (c) is 20
in zero
on the
day of
, greater, than (d), party is NOT INDIGENT. and at any recessed
at
o'clock in the
noon,
____If (c) isadjourned date, to testify and give evidence as a witness in this action on the part of the
more than zero (0) but less than (d), party is INDIGENT AND ABLE TO CONTRIBUTE.
or
Assessment Amount $________
X. Recommendation
Should this recommendation be modified due to anticipated length or complexity of case? (circle one) Yes
No
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
If yes, explain ______________________________________________________________________________________
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as
____________________________________________________________________________________________________a
result of your failure to comply.
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Witness, Honorable
, one of the Justices of the
Other considerations or comments ________________________________________________________________________
Court in
County,
day of
, 20
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
(Attorney must sign above and type name below)
The above constitutes my recommendation to the court. I have explained my recommendation to the party.
Screening Agent/Witness (please print)_______________________________________________ Date_________________
Attorney(s) for
Signature____________________________________________ Agency/Organization_______________________________
XI. Finding
____Indigent
____Not Indigent
Office and P.O. Address
_____Indigent and Able to Contribute
Assessment $______________________
Judge or Judge's Designee___________________________________________ Title_______________________________
OAC INDIG 1A691
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
American LegalNet, Inc.
www.USCourtForms.com