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2. INDIGENCY SCREENING FORM- REQUEST FOR APPOINTMENT OF ATTORNEY

   Complete this form if you are requesting the court to appoint an attorney in a pending criminal case filed in the Bainbridge Is. Municipal Court. The named Defendant should complete this form. Do not complete this form for someone else unless that person needs assistance due to disability. 

   This online form is offered for convenience. The answers will be submitted to the court email address, which will be provided to the Judge at the next hearing.

   If you prefer to complete a paper form and submit that to the court via email, fax, or in-person, the form is available on the court website: Court Forms & Resources | Bainbridge Island, WA - Official Website (bainbridgewa.gov) 

   If there is a question that does not apply to you, you may list N/A or none.

   You are submitting this document as a declaration under penalty of perjury. By completing this form, you understand that the court may require verification of the information provided.

4. First Name(s)*
5. Last Name(s)*
7. Mailing Address (including any Apt #)*
9. City*
10. State*
11. Zip*
13. Email address*
14. Phone Number*
16. Do you receive any of the following public assistance?*

    1. None
    2. Welfare
    3. Food Stamps
    4. SSI
    5. Medicaid
    6. Aged, blind, disabled assistance program
    7. Other

    Check all that apply

17. Describe other public assistance recieved:*
18. Do you work or have a job?*

    1. Yes
    2. No
20. How much money do you make per month?*

    Include all forms of income from jobs, unemployment, social security, pension, or worker's compensation.

21. Employer's Name*
22. Employer's Phone Number*
24. Do you have a spouse or partner that lives with you?*

    1. Yes
    2. No
25. How much money does your spouse/ partner make per month?*

    Include all forms of income from jobs, unemployment, social security, pension, or worker's compensation.

26. How many children reside in your household?*
28. How many people, including yourself, do you support financially?*
29. Do you receive money from any other source? If yes, describe source and monthly amount.*
31. Do you own a home or property?*
32. What is the value of home/ property (approximate)?*
33. What is your mortgage amount and monthly payment?*
35. Do you own a vehicle?*
36. Year, make, and model*
37. What is the monthly payment for any loan on the vehicle?*
39. How much money do you have in checking and/or savings accounts?*
40. How much money do you have in stocks, bonds, or other investments?*
41. How much are your routine living expenses per month (rent, food, utilities, transportation)?*
43. Other than routine living expenses such as rent, utilities, food, or transportation, do you have other expenses such as child support payments, court-ordered fines, or medical bills? If so, please describe:*
44. Do you have money to hire a private attorney? *
46. Do you certify under penalty of perjury under Washington State law that the information you provided in this form is true and correct?*

    Any answer other than YES will result in you NOT being considered by the court for appointment of an attorney. 

47. Type your full name as your electronic signature to this form.*
Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field