[Rule 15.2(c)]

SUPERIOR COURT OF WASHINGTON

FOR ____________ COUNTY

[Name of Plaintiff]

Plaintiff, )

) No. [trial court]

v. )

) Motion for Order of Indigency-

) (Criminal), (Juvenile Offense),

) (Dependency), (Termination),

) (Commitment), (Civil Contempt),

) (Habeas Corpus), (Appeal

) involving a Constitutional or

) Statutory Right to Counsel) Case

[Name of defendant] )

Defendant. )

)

______________________, (defendant) (respondent) (petitioner), files a notice of appeal in the above-referenced (criminal), (juvenile offense), (dependency), (termination), (commitment), (civil contempt), (habeas corpus), (appeal involving a constitutional or statutory right to counsel) case, and moves the court for an Order of Indigency authorizing the expenditure of public funds to prosecute this appeal (wholly at public expense) (partially at public expense).

(Defendant) (Respondent) (Petitioner) was found indigent by order of this court on . There has been no change in (defendant) (respondent) (petitioner)’s financial status since that time, and (defendant) (respondent) (petitioner) continues to lack sufficient funds to seek review in this case.

(Defendant) (Respondent) (Petitioner) asks the court to order the following to be provided at public expense: all filing fees; attorney fees; preparation, reproduction, and distribution of briefs; preparation of verbatim report of proceedings; and preparation of necessary clerk’s papers.

The following certificate is made in support of this motion.

DATED: ___________________

Signature

__________________________

(Defendant) (Respondent) (Petitioner)

Signature

__________________________

Name of Attorney for (Defendant) (Respondent) (Petitioner)

WSBA #___________________

CERTIFICATE

I, __________________________________, certify as follows:

1. That I have previously been found indigent by this court.

2. That the highest level of education I have completed is:

( ) Grade School ( ) High School ( ) College or greater

3. That I have held the following jobs:

4. That I: ( ) have not received job training

( ) have received the following job training:________________________________

__________________________________________________________________

5. That I:

( ) do not have a mental or physical disability that would affect my ability to work

( ) have the following mental or physical disability that would affect my ability to work:_____________________________________________________________

__________________________________________________________________

6. That I:

( ) do not have children or family members that normally depend on me for financial support

( ) have the following children or family member that normally depend on me for support ___________________________________________________________

__________________________________________________________________

7. That I:

( ) do not anticipate my financial condition improving in the foreseeable future through inheritance, sale of land, or similar.

( ) anticipate my financial condition improving in the foreseeable future as follows: __________________________________________________________

_________________________________________________________________

_________________________________________________________________

I, ___________________________, certify under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.

__________________________

Date

__________________________

Name of (Defendant) (Respondent) (Petitioner)

__________________________

Place

[Adopted effective September 1, 1994; amended effective December 24, 2002; September 1, 2010; January 31, 2017.]