IN THE SUPERIOR COURT OF THE STATE OF WASHINGTON

IN AND FOR THE COUNTY OF KING

STATE OF WASHINGTON, Plaintiff, v. DEFENDANT'S NAME, Defendant	) ) ) ) ) ) ) ) ) )	CAUSE NO. ### NOTICE OF APPEAL TO THE COURT OF APPEALS (CLERK’S ACTION REQUIRED)

Defendant seeks review by the Court of Appeals of the State of Washington, Division I, of Judgment and Sentence entered on _____________. A copy of the decision is attached to this notice.

Respectfully submitted this _____ day of _____________,__________.

Attorney for Plaintiff
Attorney Name, WSBA No. ### Attorney for the Defendant
Name and Address of Defendant: Defendant's Name:

IN THE SUPERIOR COURT OF THE STATE OF WASHINGTON

IN AND FOR THE COUNTY OF KING

STATE OF WASHINGTON, Plaintiff, v. DEFENDANT'S NAME, Defendant	) ) ) ) ) ) ) ) ) )	CAUSE NO. ### MOTION AND DECLARATION FOR AN ORDER TO PROCEED IN FORMA PAUPERIS ON APPEAL

Defendant moves that the Court enter an Order finding that Defendant is unable by reason of poverty to pay for expenses of appellate review, that the costs set forth in the accompanying Declaration be waived or provide at public expense, and that trial counsel be allowed to withdraw upon the appointment of appellate counsel for defendant.

In support thereof Defendant states as follows:

The Defendant is indigent and unable to pay the expenses of Defendant appeal. (See Attached Declaration)

The appeal is taken in good faith. (See attached Declaration)

In addition to the relevant Clerk’s Papers and Exhibits, the following hearing needs to be transcribed in order to adequately review the issues listed and relief requested on Defendant’s declaration:

Pretrial hearing Dates(s)	to
Judge
Trial (except voir dire Dates(s)	to
And opening/closing) Judge
Sentencing Hearing Dates(s)	to
Judge
Other Dates(s)	to
Judge

That a copy of the above record shall be provided to defendant’s counsel and the prosecuting attorney for their joint use.

That the preparation of clerk’s papers shall be at public expense.

That the costs of reproduction of appellant’s briefs shall be at public expense.

That trial counsel be allowed to withdraw as counsel effective upon the appointment of appellate counsel by the clerk of the Court of Appeals, Division I. Payment for expenses of this appointment and assignment procedures are authorized by contract with the Office of the Administrator for the Courts.

The above portions of the record are necessary for compliance with State v. Atteberrry, 87 Wn.2d 556 P.2d 1053 (1976; Griffin v. Illinois, 351 U.S. 12, 76 S.Ct. 585, 100 L.Ed. 891 (1956); Draper v. Washington, 372 U.S. 487, 83 S.Ct. 774, 9 L.Ed.2d 899 (1963) and Eskridge v. Washington State Board of Prison Terms and Paroles, 357 U.S. 214, 78 S.Ct. 1061, 2 L.Ed. 1269 (1958).

Respectfully submitted this _____ day of _____________,____________.

Attorney Name, WSBA No. ###
Attorney for the Defendant

IN THE SUPERIOR COURT OF THE STATE OF WASHINGTON

IN AND FOR THE COUNTY OF KING

STATE OF WASHINGTON, Plaintiff, v. , Defendant	) ) ) ) ) ) ) ) ) )	CAUSE NO. DECLARATION OF DEFENDANT

, the Defendant herein, states:

FINANCIAL DATA

ASSETS AND INCOME OF DEFENDANT

Employment History

Name of Employer	Dates of Employment	Monthly Income

Other Sources of Income

____________________________________________________________________________________________________________________

Assets (e.g. car, bank accounts, money on hand, etc.)

Item	Estimated Value

Current Total Assets and Income

Monthly Income	$
Total Assets:

EXPENSES AND LIABILITIES

Dependents. The following persons are dependent upon me for financial support:

Name	Age	Relationship

Monthly Expenses (e.g. rent, mortgage payments, food, utilities, notes, etc.)

Item	Monthly Expense	Balance Due (if any)
Rent
Food
Transportation (Metro)
Insurance
Municipal Court
Misc.

Current Total Expenses and Liabilities

Monthly Expense:	$
Long Term Liabilities:

Defendant can contribute the following toward expenses of appeal:

$_____________, and has previously been determined indigent by the Office of Public Defense.

APPEAL DATA

The nature of the case defendant is appealing is: _____________

Defendant is seeking the following relief:

Reversal of his conviction(s);

Reversal and remand for a new trial;

New Sentencing hearing:

Vacation of special verdicts;

Other ________________________

I wish all issues reviewed which may result in the relief requested above. More specifically, I wish the following issues reviewed:

The costs sought to be waived or provided at public expense are: a) Filing fee; b) Certified Copy, in forma pauperis Order Appointing Counsel; c) Report of Proceedings; d) Clerk’s Papers; e) Cost of reproducing brief on appeal; f) Costs of professional services of appointed counsel and any actual expenses incurred by said counsel, excluding normal overhead; g) Other:________________.

I believe my appeal is in good faith and has probable merit.

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

Date and Place	, Defendant

I am fluent in the _____________ language, and I have translated this entire document for the Defendant from English into that language. The defendant has acknowledged his or her understanding of both the translation and the subject matter of this document. I certify under

penalty of perjury under the laws of the State of Washington that the foregoing is true and accurate.

SIGNED in ___________, Washington, this _____ day of _____, __________.

Interpreter

IN THE SUPERIOR COURT OF THE STATE OF WASHINGTON

IN AND FOR THE COUNTY OF KING

STATE OF WASHINGTON, Plaintiff, v. DEFENDANT'S NAME, Defendant	) ) ) ) ) ) ) ) ) )	CAUSE NO. ### ORDER AUTHORIZING APPEAL IN FORMA PAUPERIS, APPOINTMENT OF COUNSEL AND PREPARATION OF RECORD

THIS MATTER having come on before the undersigned Judge of the above-entitled Court, upon the motion of defendant, and the Court having considered the affidavit in support of the motion, and being fully advised, now, therefore

IT IS ORDERED

That the defendant is unable by reason of poverty to pay for any of the expenses of appellate review.

That the defendant cannot contribute anything toward the costs of appellate review.

That the filing fee is waived.

That the statement of facts shall be prepared at public expense and shall contain a verbatim report of the following proceedings, all of which are necessary for review of assignments of error:

Pretrial hearing Dates(s)	to
Judge
Trial (except voir dire Dates(s)	to
and opening/closing) Judge
Sentencing Hearing Dates(s)	to
Judge
Other Dates(s)	to
Judge

That a copy of the above record shall be provided to defendant’s counsel and the prosecuting attorney for their joint use.

That the preparation of clerk’s papers shall be at public expense.

That the costs of reproduction of appellant’s briefs shall be at public expense.

That trial counsel be allowed to withdraw as counsel effective upon the appointment of appellate counsel by the clerk of the Court of Appeals, Division I. Payment for expenses of this appointment and assignment procedures are authorized under contract with the Office of the Administrator for the Courts.

Co-defendants, if any, are listed below by case name and superior court number:

_____________

That counsel on appeal, or his representative, is authorized to remove the clerk’s file from the Clerk’s Office for one day for the purpose of reproducing clerk’s papers and designating the record on appeal

DONE IN OPEN COURT this _____ day of __________________. _________.

JUDGE

Presented By:

Attorney Name, WSBA No. ### Attorney for the Defendant

IN THE SUPERIOR COURT OF THE STATE OF WASHINGTON

IN AND FOR THE COUNTY OF KING

STATE OF WASHINGTON, Plaintiff, v. DEFENDANT'S NAME, Defendant	) ) ) ) ) ) ) ) ) )	CAUSE NO. ### DECLARATION OF SERVICE

STATE OF WASHINGTON	)

) ss.

COUNTY OF KING	)

I, _____________________, declare under penalty of perjury of the laws of the State of Washington that the following is true and correct:

That I am an American citizen over 18 years of age; that on _____________, I personally served the attorney for plaintiff with one copy of Notice of Appeal in the above-captioned cause by delivering the same to the King County Prosecutor's Office, Appellate Unit, W554 King County Courthouse, 516 Third Avenue, Seattle, Washington 98104.