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2. First Name*
3. Last Name*
5. Address*
7. City*
8. State*
9. Zip Code*
11. Phone Number*
12. Email Address
14. Check the boxes next to any of the following types of assistance you receive:

    1. Welfare
    2. Food Stamps
    3. SSI
    4. Medicaid

    1. Poverty Related Veterans Benefits
    2. Temporary Assistance for Needy Families (TANF)
    3. Refugee Settlement Benefits
    4. Other
15. If Other, please describe
17. Do you work or have a job?*

    1. Yes
    2. No
18. If yes, what is your occupation?
19. What is your employer's name and phone number?
21. Do you have a spouse or partner that lives with you?*

    1. Yes
    2. No
22. If yes, name:
23. Spouse/Partner’s occupation & employer name:
25. Do you and/or your spouse/partner receive unemployment, Social Security, a pension, or workers compensation?*

    1. Yes
    2. No
26. If yes, please specify:
28. Please complete all that apply:
30. Monthly income from work (after deductions):
31. Spouse/partner’s monthly income from work (after deductions):
32. Contribution from any person living w/ you:
34. Interest, dividends, or other earnings:
35. Other income:
36. Other Income Source:
38. Do you and/or your spouse/partner have children residing with you? *

    1. Yes
    2. No
39. If yes, how many?
40. Including yourself, how many people in your household do you support?
42. Do you own a home? *

    1. Yes
    2. No
43. If yes, value
44. Amount Owed:
46. Do you own a vehicle? *

    1. Yes
    2. No
47. If yes, year(s) and model(s) of vehicle(s):
48. Value of vehicle(s):
49. Amount owed on vehicle(s):
51. How much money do you have in checking/savings account(s)?*
52. Stocks, bonds, or other investments? *
54. Other than routine living expenses such as rent, utilities, food, etc. do you have any other expenses such as child support payments, court-ordered fines, or medical bills, etc.? *

    1. Yes
    2. No
55. If so, describe:
57. Do you have money available to hire a private attorney? *

    1. Yes
    2. No
59. I certify under penalty of perjury under Washington State law that the above is true and correct. I give my permission for the court designated agency to verify this information and I authorize all persons listed above to release my financial information to the Gig Harbor Municipal Court, and I agree to hold them harmless for such release. I also agree to immediately report any change in my financial status to the court.*

    1. I agree.
61. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
63. Electronic Signature*
64. Date*
    Date
Leave This Blank:


67. 1. Receive an email copy of this form.
68. Email address

    This field is not part of the form submission.

69. Submit

* indicates a required field