Indigent Hearing Request

INDIGENT HEARING REQUEST
Defendant's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone #*
Format: (000) 000-0000.
Date of Birth*

MonthDayYear
Date
Drivers License or ID
Email
example@example.com
I request an INDIGENT HEARING on the following citation(s) and offense(s) listed below.
Citation Number - 1*
Offense*
Amount
Citation Number - 2
Offense
Amount Due
Citation Number - 3
Offense
Amount Due
Citation Number - 4
Offense
Amount Due
I understand I am required to complete in full the Lacy Lakeview Municipal Court Financial Affidavit and provide it completed to the Judge at the hearing with ALL supporting documents.

I understand that a hearing will not take place if all required documentation is not brought to the scheduled Indigent Hearing.

I understand that a notice will be mailed to the address I provided above and understand that if this written request is not signed and/or is incomplete the request is automatically denied (no hearing will be scheduled)

I understand that if I am NOT found indigent (individuals living at or below 125% of the federal poverty level) then I will be expected to make payment at the hearing.
Defendants Signature*

Clear
Date*

MonthDayYear
Date
If the cases(s) are in warrant status they will remain in effect until the Judge orders the warrant(s) recalled.
Upload a copy of your Driver's License or State ID*

Cancelof
Should be Empty:

INDIGENT HEARING REQUEST