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APPLICATION FOR PUBLIC DEFENDER NAME: ADDRESS: PHONE NUMBER : Email (required by Public Defender ) DEFENDANT RECEIVES : □ AFDC □ GAU □ FOOD STAMPS □ SSI (not Social Security) □ APPLE HEALTH □ MEDICAID □ VETERAN’S ASSISTANCE BENEFITS (Poverty Related) □ WIC □ TANF □ REFUGEE RESETTLEMENT BENEFITS DSHS Client ID COURT CASE # : INCOME Present Employer (Name, Address & Phone How Long Employed Hours worked per week Spouse’s Employer (Name, Address & Phone How Long Employed Hours worked per week APPLICANT ’S TAKE HOME PAY (After Taxes) SPOUSE’S TAKE HOME PAY (After Taxes) NON-POVERTY BASED ASSISTANCE (Unemployment, Social Security, L&I, etc.) OTHER INCOME (Child Support, Spousal Maintenance, Rental Income, Tribal per capita, etc.) TOTAL INCOME : SUPPORT OBLIGATIONS: TOTAL NUMBER OF DEPENDENTS (Include yourself, spouse and/or children): If you are a juvenile do you live with: Both Parents her ______Father EXPENSES (For Applicant & Dependents): BASIC LIVING EXPENSES: RENT/MORTGAGE ELECTRICITY WATER/SEWER LIFE/HOUSE INSURANCE TRANSPORTATION TO CAR PAYMENT INSURANCE TOTAL BASIC LIVING COURT IMPOSED OBLIGATIONS (Specify Amount) $ BAIL/BOND PAID (This Offense) OTHER (Unusual) EXPENSES (Specify) (Medical Bills, Child Support, Prior Attorney Fees, Past Due Utility, Rent, IRS Payments, Union Dues, Collection Agency, etc) TOTAL MONTLY EXPENSES TOTAL INCOME MINUS TOTAL EXPENSES EQUAL S DISPOSABLE NET INCOME LIQUID ASSETS: CASH (On Hand/On Books, Savings, Checking, Bank Accounts) STOCKS, BONDS, CERTIFICATES OF DEPOSIT EQUITY IN REAL ESTATE EQUITY IN MOTOR VEHICLE NOT REQUIRED FOR WORK EQUITY IN ADDITONAL VEHICLES PERSONAL PROPERTY (Boats, stereo, VCR, Jewelry, Guns, etc.) TOTAL LIQUID ASSETS AFFIDAVIT AND NOTIFICATION I, (print name), do hereby certify and 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 ---PAGE BREAK--- or its designee to verify all information provided here. Verification may include a credit report. I further swear to immediately report any change in financial status to the court. I understand if bail is imposed in this matter or if my financial condition changes, I may request a re-determination. DO NOT SIGN UNTIL YOU ARE AT YOUR SCREENING MEETING. SIGNED DETERMINATION OF INDIGENCY : A. DISPOSABLE NET INCOME B. TOTAL LIQUID ASSETS C. TOTAL AVAILABLE FUNDS (A plus B) ( ) Indigent ( ) Indigent and able to contribute/Assessment: ( ) Not Eligible : □ Income □ Assets Judge or Designee MARYSVILLE MUNICIPAL COURT HOW TO APPLY FOR A COURT APPOINTED ATTORNEY WHERE: You must come in person to the: MARYSVILLE MUNICIPAL COURT 1015 STATE AVE MARYSVILLE, WA 98270 WHEN: You do not need to make an appointment. Please appear at the front counter with your paperwork completed and the items from the checklist below. You may appear Monday-Friday from 8:30 a.m. to 3:30 p.m. PLEASE BRING ALL DOCUMENTS WITH YOU. WITHOUT PROPER PAPERWORK YOU MAY BE ASKED TO COME BACK. CHECKLIST OF WHAT TO BRING WITH YOU: 1. COURT PAPERS: Any papers received with court dates. 2. INCOME a) EMPLOYMENT: Bring EVERY pay stub for wages received for the past 2 months for you and/or your spouse; b) SELF-EMPLOYMENT: Last year's income tax form; c) UNEMPLOYMENT COMPENSATION: Bring computer printout showing total benefits available and amount received each month or statements showing you are not eligible for benefits; d) PUBLIC ASSISTANCE, SOCIAL SECURITY, OR VETERAN’S BENEFITS: Bring letter and/or copy of last check received; e) INTEREST INCOME, INHERITANCE, OR SETTLEMENTS: Documentation showing income; 3. BILLS ---PAGE BREAK--- a) Proof of basic living expenses such as receipts for rent or mortgage, utilities, phone, car payments, insurance payments, child support or care, etc.; b) Proof of any other unusual living expenses such as medical/dental bills, collections, debts, court obligations etc. 4. ASSETS: Documentation of any personal items of value.