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