Public Defender Application

Public Defender Application
Name *
Case number(s) *
Address *

Street Address

Street Address Line 2

City State

Zip Code
Phone Number *
Monthly take home pay (after taxes) *
Please check any of the following types of assistance you receive:

Welfare Poverty related Veteran's Benefits Food Stamps Temporary Assistance for Needy Families SSI Refugee Settlement Benefits Medicaid Aged, Blind or Disabled Assistance Program Pregnant Women Assistance Benefits
Do you work or have a job? *

Yes No
Do you have a spouse or state-registered domestic partner that lives with you? *

Yes No
Do you and/or your spouse or state-registered domestic partner receive unemployment, social security, a pension or worker's compensation? *

Yes No
Do you receive money from any other source? *

Yes No
Do you have children residing with you? *

Yes No
Do you own a home? *

Yes No
Do you own a vehicle? *

Yes No
Including yourself, how many people in your household do you support? *
How much money do you have in your checking and savings account(s)? *
Enter $0 if none.
How much money do you have in stocks, bonds or other investments? *
Enter $0 if none.
How much are your routine monthly living expenses? (Examples: Rent, food utilities, transportation) *
Enter $0 if none.
Other than routine living expenses such as rent, food, utilities etc., do you have other expenses such as child support payments, court-ordered fines or medical bills, etc.? If so, please describe: ( Enter 'none' if none exist. ) *
Do you have money available to hire a private attorney? *

Yes No
Please check each box below after reading if you agree to the terms of this application:

The form will not be submitted until ALL of these boxes have been agreed to and checked.
*

I understand that the court may require verification of the information provided above. I agree to immediately report any change in my financial status to the court.
*

I consent to the court accessing my confidential benefit information Via the DSHS BVS (benefit verification system) Application
*

I certify under penalty of perjury under Washington State law that the above is true and correct. (Perjury is a criminal offense-see Chapter 9A72 RCMI)
Please select today's date: *

Month Day Year
Date
Signature

Clear
Once the application has been received it will be reviewed by a Judge within 1 week. Please call the court to check the status of the application.
If you want this information translated, please email TitleVICoordinator@kirklandwa.gov or call 425-587-3831.

Si usted desea esta información traducida al Español por favor envíe un mensaje al la siguientedirección electrónica: TitleVICoordinator@kirklandwa.gov o llame al número 425-587-3831.

如果您需要此信息的翻译版本，请发送电子邮件至 TitleVICoordinator@kirklandwa.gov 或拨打电话425-587-3831.

Если Вы хотите получить эту информация переведённую на Русский язык напишите по адресуTitleVICoordinator@kirklandwa.gov или позвоните 425-587-3831.
Alternate Formats:

People with disabilities may request materials in alternate formats.

Title VI: Kirkland’s policy is to fully comply with Title VI of the Civil Rights Act by prohibiting discrimination against any person on the basis of race, color, national origin or sex in the provision of benefits and services resulting from its programs and activities. Any person who believes his/her Title VI protection has been violated, may file a complaint with the City.

To request an alternate format, file a complaint or for questions about Kirkland’s Title VI Program, contact the Title VI Coordinator at 425-587-3831 (TTY Relay: 711) or TitleVICoordinator@kirklandwa.gov
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