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Juvenile  Court  -  Parent  Pay  Program

 

Instructions for Determination of Indigency Report Form

 
court image  Directions:
  • 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.
court image  Identification:
  • 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).
court image  Presumptive Eligibility:
  • Verification will be required.  Please provide your case number.
  • Tax returns may be necessary to verify annual income after taxes.
court image  Monthly Income:
  • 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.
court image  Liquid Assets:
  • IRS tax returns may be requested to verify this information.
court image  Affidavit and Notification:
  • Please print and sign your name.
  • "Place" is the city and state where you are in when you sign the form.
If you have any questions or need assistance in completing the form, please contact the Parent Pay Department at Thurston County Juvenile Court.
 

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Page Revised on March 15, 2006 Thurston County