CONFIDENTIAL
[Per RCW 10.01.160(3)]

Contact Information

 *

Contact Information

Full Name

Case Number

Street Address

City

State

Zip

Telephone Number

Email Address

Check all that apply

Check all that apply

Welfare

Food Stamps

SSI

Medicaid

Poverty Related Veterans' Benefits

Temporary Assistance for Needy Families

Refugee Settlement Benefits

Disability Lifeline Benefits

Other - Please Describe If other, type text here.

Do you work or have a job?

Do you work or have a job?

Yes

No

If Yes, What is your take home pay?

If Yes, What is your take home pay?

Monthly Take Home Pay

Occupation

Employer's Name

Employer's Phone Number

Do you have a spouse or State registered domestic partner who lives with you?

Do you have a spouse or State registered domestic partner who lives with you?

Yes

No

If Yes, does he/she work?

If Yes, does he/she work?

Yes

No

If Yes, What is their take home pay?

If Yes, What is their take home pay?

Monthly Take Home Pay

Occupation

Employer's Name

Employer's Phone Number

Do you and/or your spouse or State registered domestic partner receive unemployment, Social Security, a pension, or workers' compensation?

Do you and/or your spouse or State registered domestic partner receive unemployment, Social Security, a pension, or workers' compensation?

Yes

No

If so, which one?

Monthly amount received

 Do you receive money from any other source?

Do you receive money from any other source?

Yes

No

If Yes, how much?

Do you have children residing with you?

Do you have children residing with you?

Yes

No

If Yes, how many?

Including yourself, how many people in your household do you support?

Do you own a home?

Do you own a home?

Yes

No

If Yes, what is the value of your home?

If Yes, what is the amount owed on the home?

Do you own a vehicle?

Do you own a vehicle?

Yes

No

If Yes, what is the year/model of your vehicle(s)

Financial Information

Financial Information

How much money do you have in checking/saving account(s)

How much money do you have in stocks, bonds, or other investments?

How much are your routine living expenses (rent, food, utilities, transportation)?

Other than routine living expenses, do you have other expenses such as child support payments, court ordered fines or medical bells, etc.?

Do you have money available to hire a private attorney?

Do you have money available to hire a private attorney?

Yes

No

You must agree to the following to submit this form

 *

You must agree to the following to submit this form

I understand this communication may be subject to public disclosure laws of the State of Washington (RCW 42.56).

I understand the court may ask for verification of the information provided above. I agree to immediately report any change in my financial status to the court.

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