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Application for Assignment of Public Defender
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Lake Forest Park Municipal Court - Application for Assignment of Public Defender
CONFIDENTIAL PER RCW 10.101.020(3)
Email address (strictly confidential)
Select the types of assistance you receive:
Pregnant Women Assistance Benefits
Poverty-related Veterans Benefits
Temporary Assistance for Needy Families
Refugee Settlement Benefits
Aged, Blind or Disabled Assistance Program
Other, please describe below:
Describe the other types of assistance you receive:
Do you work or have a job?
If so, monthly take-home pay:
Employer's name and phone number:
Do you have a spouse that lives with you?
Does he/she work?
If so, monthly take-home pay and employer name:
Do you and/or your spouse receive unemployment, Social Security, a pension, or workers' compensation?
If so, which one, and amount.
Do you receive money from any other source?
If so, how much?
Do you have children living with you?
If so, how many?
Including yourself, how many people in your household do you support?
Do you own a home?
If so, what is the value?
Do you own a vehicle or vehicles?
If so, year(s) and model(s) of your vehicles:
How much money do you have in checking/savings account(s)?
How much money do you have in stocks, bonds, or other investments?
How much are your monthly routine living expenses (rent, food, utilities, transportation)?
Other than routine monthly living expenses such as rent, utilities, food, etc., do you have other expenses such as child support payments, court-ordered fines, medical bills, etc.?
If so, describe:
Do you have money available to hire a private attorney?
After completing the above, please READ and ELECTRONICALLY SIGN, below.
1) I understand the court may require verification of the information provided above.
2) I agree to immediately report any change in my financial status to the court.
3) I certify under penalty of perjury under the laws of Washington State that I have read the foregoing statements in the application, know the contents thereof, and believe them to be true and correct. (Perjury is a criminal offense-see Chapter 9A.72 RCW).
Electronic Signature Agreement:
I agree. Electronic signature.
By checking the "I agree" box above, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
Last name, first name, middle initial
OPT-IN for Court Date Reminder Text Message Reminders
Please provide your cell phone number below to opt-in for text message reminders of future court hearings. Non-delivery or non-receipt of a text message does not release you of your obligation to appear if you have been previously noticed. Standard text messaging rates may apply.
Opt-in Cell Phone Number
COURT USE ONLY
Recoupment of public defender fees are based on a sliding scale, depending on the level of indigence.
Eligible for a public defender at no expense.
Eligible for a public defender but able to contribute $100-$350 (sliding scale).
Rescreen in future regarding change of income (e.g. defendant works seasonally).
Not eligible for a public defender.
If eligible for a public defender on sliding scale, enter contribution amount:
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