HomeMy Public PortalAboutPublic Defender Indigency case 3A0804450 CN CONNELL HOLLY (2023-12-29)Name CONNELL, HOLLY
SUZANNE
Citation Number 3A0804450
Address 7508 159TH PL.
NE #317,
redmond wa 98052
(Street)(City)(State)(Zip)
Welfare
Food Stamps
SSI
Medicaid
General Assistance
Poverty Related Veterans Benefits
T emporaryAssistance for Needy Families
Refugee Settlement Benefits
Other – Please Describe
Adult Behavioral Disability
2. Do you work or have a job? Yes No If yes, occupation:
Employer’s name & phone number
3. Do you have a spouse or partner who lives with you? Yes No If yes, Name:
Occupation & Employer’s Name
4. Do you and/or your spouse/partner receive unemployment, Social Security, a pension, or workers’,
compensation? Yes No. If yes, please specify . Amount $
a.Monthly income from work (after
deductions)
b.Spouse or partner’s monthly income from
work (after deductions)
c.Contribution from any person living w/you
d.Interest, dividends, or other earnings
e.Other income (specify)$
$ 0
$ 0
$ 0
$ 0
$
6. Do you and/or your spouse/partner have children residing with you? Yes No
If yes, how many? 0
8. Do you own a home? Yes No If yes, Value Amount owed
King County
Bothell Municipal Court
10116 NE 183rd St
Bothell, WA. 98011
Phone (425) 487-5587, Fax: 425-487-5580
municourt@bothellwa.gov
Public Defender Indigency Screening
Form
City of Bothell , Plaintiff vs. CONNELL, HOLLY SUZANNE,
Defendant
AKA(s):
DOB: 7/24/1986 CCN:
Case Numbers: 3A0804450
1.Check below any of the following types of assistance you receive:
5. Please complete all that applies:
7. Including yourself, how many people in your household do you support? 1
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9. Do you own a vehicle(s) Yes No If yes, year(s) and model(s) of vehicle(s)
Value of vehicle(s) Amount owed on vehicle(s)
10. How much money do you have in checking/saving account(s) $ 15.00
Stocks, bonds or other investments? 0
11. Other than routine living expenses such as rent, utilities, food, etc, do you have other expenses such
as child support payments, court ordered fines or medical bills, etc? If so, describe: child support
$200/mo, soon to be reduced to $25/mo
12. Do you have money available to hire a private attorney? Yes No
13. Please read and sign the following:
I understand the court may require verification of the information provided above.
I agree to immediately report any change in my financial status to the court.
I certify under penalty of perjury under Washington State law that the above is true and correct.
(Perjury is a criminal offense-see Chapter 9A.72 RCW)
Date:
Defendant’s Signature
Served on Defendant
For Court Use Only – Determination of Indigency
Eligible for a public defender at no expense
Not eligible for a public defender
Eligible for a public defender but must contribute $
Re-screen in future regarding change of income (e.g. defendant works seasonally)
Judge/Pro-Tem
Name: mara.rozzano
ORDER APPOINTING COUNSEL
I hereby appoint and the defendant has received contact information for attorney(s) at
law, to represent the above named defendant in the above listed criminal cause number(s).
Address: 7508 159TH PL. NE #317,REDMOND,WA,98052
Email: holly_connell@yahoo.com Cell Phone: Home Phone:
I authorize courtesy text/ email reminders of court dates payment due dates Message and data
rates may apply.
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