Motions for Waiver of Interest

1. Fill out the attached motion form with your request for
waiver of interest and complete the attached Financial
Declaration.

2. File the completed forms at the Clerk’s Office Criminal

Counter. The original motion will be filed in the court file.

3. The clerk will make a copy to send to the collections unit for
review. You will be notified by the Collections Unit if any
further information is needed.

4. The collections unit staff will present the motion on the next
payment review docket for determination by the court, and
you will be notified of the Court’s decision within 2 to 3
weeks. You do not need to appear in court.
 IN THE SUPERIOR COURT OF THE STATE OF WASHINGTON
IN AND FOR THE COUNTY OF CLARK
STATE OF WASHINGTON,

No.________________________
vs.
Request / Motion for__________
___________________________
Defendant. ___________________________
___________________________
(MT)

Comes now the defendant, ______________________________and requests / moves the Court to

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Signature of Defendant Print or Type Name
Address: ______________________________________

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Motion (MT) Page 1 of 2

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Motion (MT) Page 2 of 2

 IN THE SUPERIOR COURT OF THE STATE OF WASHINGTON
IN AND FOR THE COUNTY OF CLARK
STATE OF WASHINGTON,
Plaintiff,
vs. No.
Financial Declaration
Defendant. (FNDCLR)

Name: Date of Birth:

I. Summary of Basic Information

Declarant’s Total Monthly Net Income (from § 3.3 below) $

Declarant’s Total Monthly Household Expenses (from § 5.9 below) $
Declarant’s Total Monthly Debt Expenses (from § 5.11 below) $
Declarant’s Total Monthly Expenses (from § 5.12 below) $

II. Personal Information

2.1 Occupation: _______________________________________
2.2 The highest year of education completed: ________________
2.3 Are you presently employed? [ ] Yes [ ] No

a. If yes: (1) Where do you work. Employer's name and address must be listed on the
Confidential Information Form.

(2) When did you start work there (month/year)? _______________________

b. If no: (1) When did you last work (month/year)? _______________________

(2) What were your gross monthly earnings? $
(3) Why are you presently unemployed?

Financial Declaration (FNDCLR) - Page 1 of 6

 III. Income Information

3.1 Gross Monthly Income

If you are paid on a weekly basis, multiply your weekly gross pay by 4.3 to determine your monthly wages
and salaries. If you are paid every two weeks, multiply your gross pay by 2.15. If you are paid twice
monthly, multiply your gross pay by 2. If you are paid once a month, list that amount below.

$ ___________
a. Wages and Salaries $
b. Interest and Dividend Income $
c. Business Income $
d. Spousal Maintenance Received
From ____________________________ $
e. Other Income $
f. Total Gross Monthly Income (add lines 3.1a through 3.1e) $
g. Actual Gross Income (Year-to-date) $

3.2 Monthly Deductions From Gross Income

a. Income Taxes $
b. FICA/Self-employment Taxes $
c. State Industrial Insurance Deductions $
d. Mandatory Union/Professional Dues $
e. Pension Plan Payments $
f. Spousal Maintenance Paid $
g. Normal Business Expenses $
h. Total Deductions from Gross Income $
(add lines 3.2a through 3.2g)

3.3 Monthly Net Income $

3.4 Miscellaneous Income

a. Child support received from other relationships $
b. Other miscellaneous income (list source and amounts)
__________________________________________ $
__________________________________________ $
__________________________________________ $
__________________________________________ $

Financial Declaration (FNDCLR) - Page 2 of 6

 c. Total Miscellaneous Income (add lines 3.4a through 3.4b) $

3.5 Income of Other Adults in Household $

IV. Available Assets

4.1 Cash on hand $
4.2 On deposit in banks $
4.3 Stocks and bonds, cash value of life insurance $
4.4 Other liquid assets: $

V. Monthly Expense Information

Monthly expenses for myself and ____________ dependents are:

5.1 Housing
Rent, 1st mortgage or contract payments $
Installment payments for other mortgages or encumbrances $
Taxes & insurance (if not in monthly payment) $
Total Housing $

5.2 Utilities
Heat (gas & oil) $
Electricity $
Water, sewer, garbage $
Telephone $
Cable $
Other $
Total Utilities $

Financial Declaration (FNDCLR) - Page 3 of 6

5.3 Food and Supplies
Food for ___________ persons $
Supplies (paper, tobacco, pets) $
Meals eaten out $
Other $
Total Food Supplies $

5.4 Children
Day Care/Babysitting $
Clothing $
Tuition (if any) $
Other child-related expenses $
Total Expenses Children $

5.5 Transportation
Vehicle payments or leases $
Vehicle insurance & license $
Vehicle gas, oil, ordinary maintenance $
Parking $
Other transportation expenses $
Total Transportation $

5.6 Health Care (Omit if fully covered)

Insurance $
Uninsured dental, orthodontic, medical, eye care expenses $
Other uninsured health expenses $
Total Health Care $

5.7 Personal Expenses (Not including children)

Clothing $
Hair care/personal care expenses $
Clubs and recreation $
Education $
Books, newspapers, magazines, photos $
Gifts $
Other $
Total Personal Expenses $
Financial Declaration (FNDCLR) - Page 4 of 6
5.8 Miscellaneous Expenses
Life insurance (if not deducted from income) $
Other _____________________________________________ $
Other _____________________________________________ $
Total Miscellaneous Expenses $

5.9 Total Household Expenses (The total of Paragraphs 5.1 through 5.8) $

5.10 Installment Debts Included in Paragraphs 5.1 Through 5.8

Description Month of
Creditor of Debt Balance Last Payment

5.11 Other Debts and Monthly Expenses not Included in Paragraphs 5.1 Through
5.8
Description Month of Amount of
Creditor of Debt Balance Last Payment Monthly
Payment
$
$
$
$
$
$
$

Total Monthly Payments for Other Debts and Monthly Expenses $

5.12 Total Expenses (Add Paragraphs 5.9 and 5.11) $

Financial Declaration (FNDCLR) - Page 5 of 6

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

Signed at ________________________, [City] _________ [State] on ____________________ [Date].

Signature of Declarant Print or Type Name

Address:__________________________________________

__________________________________________

H:\PVDOCKET\FNDCLR01.DOC

Financial Declaration (FNDCLR) - Page 6 of 6