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Financial Questionnaire to Establish Indigency


  1. 1. Step One
  2. 2. Step Two
  • Step One

    1. Part I- General Information
    2. Note: If you are applying for indigent defense services, you may be charged with an application fee.
    3. Are you receiving welfare or participating in another government based income maintenance program?*
    4. Are you only completing this form for installment payments of your fine?*
    5. Are you only charged with traffic or parking offenses?*
    6. If you answered "Yes" to all of the above 3 questions, go to Part VII and complete the Certification.
    7. Which income tax returns did you file last year?
    8. Have you posted bail for this charge?
    9. Part II- Employment History
    10. Are you now employed?
    11. Current employer, if employed. If unemployed, last employer and date last employed.
    12. Part III- Income & Assets (include all assets you own by yourself or with someone else)
    13. $
    14. Do you receive alimony or child support?
    15. By Court Order?
    16. Does anyone contribute to the payment of your expenses?