Fill and Sign the Chapter 6 Case Procedures Judiciary of Virginia Form

STATE OF WASHINGTON Determination Of Indigency Report I. Identification County_____________________________________ Court_________________________________________________ Jurisdiction (check one) ( ) Superior ( ) District ( ) Municipal Name of City___________________________ Applicant's Name __________________________________________ Case Number: ____________________________ Case Type (check the category corresponding to the most serious charge) _____(1) Felony - Class A+ _____(5) Juvenile Felony - Class A+ _____( 9) Dependency _____(2) Felony - Class A _____(6) Juvenile Felony - Class A _____(10) Civil Commitment _____(3) Felony - Class B or C _____(7) Juvenile Felony - Class B or C _____(11) Civil Contempt _____(4) Misdemeanor _____(8) Juvenile - Misdemeanor _____(12) Other (specify)_______________ Charges___________________________________________________________________________________________ Applicant's Address_________________________________________________________________________________ (Street) (City) (State) (Zip Code) Applicant's Telephone (___) ____ - _______ Date of Birth ____ /____ /____ Social Security # (optional) ____ /____ /____ Occupation______________________ Employer__________________________________________________________ (Name) (Address) (Telephone) II. Support Obligations Total Number Dependents (include applicant in count) ____ If juvenile defendant, does he/she live with parents? (circle) Y N If yes: Father's name _________________________ Mother's name (include maiden) ___________________________ III. Presumptive Eligibility (check all that apply) a. __ Party is indigent because receives public assistance in form of: ( ) AFDC 1 ( ) General Assistance ( ) Food Stamps ( ) Medicaid ( ) Poverty-Related V.A. 2 Benefits ( ) SSI 3 ( ) Refugee Resettlement Benefits ( ) Other; specify________ Case Number_____________________Verified? ______ Method_____________________________________________ b. __ Party is indigent because committed to a public mental health facility. Verified? ________ Method: __________________________________________________________________________ c. __ Party is indigent because annual income, after taxes, is 125% or less of current federally established poverty level. $______________________ Specify annual income after taxes Verified? _______ Method: ___________________________________________________________________________ If Section III, a, b, or c applies, complete only Sections V III, X and XI. Submit report to Court. If Section III is not applicable, complete all remaining sections. IV. Monthly Income Verified? a. Monthly take-home pay (after deductions) $_______ Y N b. Spouse's take-home pay (enter N/A if conflict) $_______ Y N c. Contribution from any person domiciled with applic ant and helping defray his/her basic living costs $_______ Y N d. Interest, dividends, or other earnings $_______ Y N e. Non-poverty based assistance ( Unemployment, Social Security, Workers Compensation, pension , annuities) (DON'T include poverty-based assistance. See IV. a ) $_______ Y N f. Other income (specify) __________________________________ $_______ Y N Total Income $_______ V. Monthly Expenses (for applicant and dependents; average where applicable) a. Basic Living Costs - Shelter (rent, mortgage, board) $_______ Y N Utilities (heat, electricity, water); enter 0 if included in cost of shelter $_______ Y N Food $_______ Y N Clothing $_______ Y N Health Care $_______ Y N Transportation $_______ Y N Loan Payments (specify)__________________________________ $_______ Y N b. Court imposed obligations (check) ___fines ___c ourt costs ___restitution ___support ___other $_______ Y N c. Bail/bond paid or anticipated (this offense) $_______ Y N d. Other expenses (specify) _____________________________________ $_______ Y N Total Expenses $_______ 1 Aid to Families with Dependent Children 2 Veterans' Administration 3 Supplemental Security Income VI. Total Income Part IV, minus Total Expenses Part V Disposable Net Monthly Income $________ VII. Liquid Assets Verified? a. Cash, savings, bank accounts (include joint accounts) $________ Y N b. Stocks, bonds, certificates of deposit $________ Y N c. Equity in real estate $________ Y N d. Equity in motor vehicle required for employment, IF over $3,000 ( list overage: value minus $3,000) $________ Y N Make of car___________________________ Year_______________ e. Equity in additional vehicles (list total value) $________ Y N f. Personal property (jewelry , boat, stereo, etc.) $________ Y N Total Liquid Assets $________ VIII. Affidavit and Notification I, _______________________________________(print name) do hereby certify (or 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 to verify all informat ion provided here. I further swear to im mediately report any change in financial sta tus to the court. I understand that if bail is imposed in this matter or if my financial condition changes I may request a redetermination. Signed____________________________________ Date___________________ Place______________________________ IX. Determination of Indigency a. Disposable Net Monthly Income (from Section VI) $________ b. Total Liquid Assets (from Section VII) + $________ c. Total Available Funds (a plus b) = $________ d. Anticipated Cost of Counsel for Offense Type(s) $________ ____If (c) is zero (0) or less, party is INDIGENT. ____If (c) is greater than (d), party is NOT INDIGENT. ____If (c) is more than zero (0) but less than (d), party is INDIGENT AND ABLE TO CONTRIBUTE. Assessment Amount $________ X. Recommendation Should this recommendation be modified due to anticipated l ength or complexity of case? (circle one) Yes No If yes, explain ______________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Other considerations or comments ________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ The above constitutes my recommendation to the court. I have explained my recommendation to the party. Screening Agent/Witness (please print)_______________________________________________ Date_________________ Signature____________________________________________ Agency/Organization_______________________________ XI. Finding ____Indigent ____Not Indigent _____Indigent and Able to Contribute Assessment $______________________ Judge or Judge's Designee___________________________________________ Title_______________________________ OAC INDIG 1A691