Instructions for Determination of Indigency Report Form

• Read through the form completely and carefully before completing.
• Fill out each area, as it applies, as completely as possible.
• All information should be printed or typed.
• Applicant fills out everything except Sections IX, X, and XI.
• Three months of current pay stubs are required with report form.  If pay stubs are not available, then two years of tax returns are required.  Other verification may be requested.

• Please print or type juvenile's name on the upper right hand corner of the form.
• The parent(s), as the applicant(s), completes the form with his or her (their) income, expenses, and assets information.
• A daytime phone number must be included on the form.
• Leave court information blank (i.e., case number, case type).

• Verification will be required.  Please provide your case number.
• Tax returns may be necessary to verify annual income after taxes.

• Any citizen who declines to give this information will be taken as agreeing to pay the maximum amount.
• Monthly take-home is described as gross pay, less involuntary deductions (federal withholding tax, FICA, L&I, mandatory pension, union dues, etc.).
• A tax return may be required to verify information about non-wage income such as rental, interest, etc.

• IRS tax returns may be requested to verify this information.

• Please print and sign your name.
• "Place" is the city and state where you are in when you sign the form.

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