Application for Court Appointed Attorneys
Clark County District Court
Washington
This form is NOT for Superior Court cases
Case #:
Applicant
First Name
Middle Name
Last Name
Alias/Maiden Name(s)
Date of Birth
Phone
Email
Street Address
Address Line 2
City
State
-select-
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisianna
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Province / Region / Other
Province / Region
Zip
Country
United States of America
Canada
Mexico
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua & Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire
Bosnia & Herzegovina
Botswana
Brazil
British Indian Ocean Ter
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canary Islands
Cape Verde
Cayman Islands
Central African Republic
Chad
Channel Islands
Chile
China
Christmas Island
Cocos Island
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote DIvoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Ter
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Great Britain
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guyana
Haiti
Hawaii
Honduras
Hong Kong
Hungary
Iceland
Indonesia
India
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea North
Korea South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malaysia
Malawi
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Midway Islands
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Nambia
Nauru
Nepal
Netherland Antilles
Netherlands (Holland, Europe)
Nevis
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Norway
Oman
Pakistan
Palau Island
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Island
Poland
Portugal
Puerto Rico
Qatar
Republic of Montenegro
Republic of Serbia
Reunion
Romania
Russia
Rwanda
St Barthelemy
St Eustatius
St Helena
St Kitts-Nevis
St Lucia
St Maarten
St Pierre & Miquelon
St Vincent & Grenadines
Saipan
Samoa
Samoa American
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Tahiti
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Is
Tuvalu
Uganda
United Kingdom
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela
Vietnam
Virgin Islands (Brit)
Virgin Islands (USA)
Wake Island
Wallis & Futana Is
Yemen
Zaire
Zambia
Zimbabwe
General Delivery
Marital Status
Single
Married
Separated
Widowed
Divorced
Number of dependent minor children who reside with you that you support
Number of dependent minor children for which you pay child support
Are you current in your child support payments?
Yes
No
na
Public Assistance Currently Receiving
(RCW 10.101.010(3)(a))
Welfare/TANF
Food Stamps
Medicaid
Poverty Related Veterans’ Benefits
Aged, Blind, or Disabled Assistance
Medical Care Services (RCW 74.09.035)
Pregnant Women Assistance
Refugee Resettlement Benefits
Supplemental Security Income (Designed to assist aged, blind, and disabled or to assist in meeting basic needs)
Other
Current Financial Status
1. EMPLOYMENT
Employer
Employment Type
Full Time
Part Time
Seasonal
If Unemployed, how long?
2. INCOME /PER MONTH
Salary/Wages (Take Home Pay)
Spouse/Registered Domestic Partner’s income
Social Security Retirement Benefits
Other Retirement Received
Pension Received
Unemployment / Worker's Compensation
Alimony or Maintenance Received
Child Support Received
Other Source of Income
3. AVAILABLE MONEY
Cash On Hand
Checking Account(s)
Savings Account(s)
Stocks, Bonds, Trusts, CDs, Other
4. ASSETS
Value of Real Estate (home, land, bldg)
Cash Value Minus Amount Owed
Value of Vehicle(s)
Cash Value Minus Amount Owed
Vehicle Make
Vehicle Model
Vehicle Year
Monthly Expenses
1. HOUSING COSTS
Monthly Rent or Mortgage
Utilities
(Electricity, Heat, etc.)
2. OTHER
Food
Transportation
Child/Health Care
Child Support Paid
Loan Payments
(not including vehicle, home, land, bldg)
Legal Financial Obligations
Other