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2. Lake Forest Park Municipal Court - Application for Assignment of Public Defender
   CONFIDENTIAL PER RCW 10.101.020(3)
4. First Name*
5. Last Name*
7. Case Number: *
9. Address1*
11. Address2
13. City*
14. State*
15. Zip*
17. Email address (strictly confidential)*
18. Phone Number:*
20. Select the types of assistance you receive:*

    1. Welfare
    2. Food Stamps
    3. SSI
    4. Medicaid
    5. Pregnant Women Assistance Benefits

    1. Poverty-related Veterans Benefits
    2. Temporary Assistance for Needy Families
    3. Refugee Settlement Benefits
    4. Aged, Blind or Disabled Assistance Program
    5. Other, please describe below:
22. Describe the other types of assistance you receive:
26. Do you work or have a job?*

    1. Yes
    2. No
27. If so, monthly take-home pay:
29. Occupation:
30. Employer's name and phone number:
32. Do you have a spouse that lives with you?*

    1. Yes
    2. No
33. Does he/she work?

    1. Yes
    2. No
35. If so, monthly take-home pay and employer name:
37. Do you and/or your spouse receive unemployment, Social Security, a pension, or workers' compensation?*

    1. Yes
    2. No
38. If so, which one, and amount.
40. Do you receive money from any other source?

    1. Yes
    2. No
41. If so, how much?
43. Do you have children living with you?*

    1. Yes
    2. No
44. If so, how many?
45. Including yourself, how many people in your household do you support?
47. Do you own a home?*

    1. Yes
    2. No
48. If so, what is the value?
49. Amount owed?
51. Do you own a vehicle or vehicles?*

    1. Yes
    2. No
52. If so, year(s) and model(s) of your vehicles:
53. Amount owed?
55. How much money do you have in checking/savings account(s)?*
56. How much money do you have in stocks, bonds, or other investments?*
57. How much are your monthly routine living expenses (rent, food, utilities, transportation)? *
59. 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.?*

    1. Yes
    2. No
60. If so, describe:
62. Do you have money available to hire a private attorney?*

    1. Yes
    2. No
66. After completing the above, please READ and ELECTRONICALLY SIGN, below.
68. 1) I understand the court may require verification of the information provided above.
70. 2) I agree to immediately report any change in my financial status to the court.
72. 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).
74. Electronic Signature Agreement:*

    1. 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.
75. Electronic Signature*
    Last name, first name, middle initial
77. Date signed:*
    Date signed:
79. 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.
81. Opt-in Cell Phone Number
85. COURT USE ONLY
Leave This Blank:


90. 1. Receive an email copy of this form.
91. Email address

    This field is not part of the form submission.

92. Submit Submit and Print

* indicates a required field