Free Application for Court-Appointed Counsel - Washington

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Application for Court-Appointed Counsel in Title VII Action Defendant(s), v. Plaintiff(s), Case Number: UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF WASHINGTON
Instructions for use:

Print Form

1. Check the above box "Highlight Fields" to show fields on this form. 2. Complete the form. 3. Print, sign the document, and file with the court.

APPLICATION FOR COURT APPOINTED COUNSEL Noted for determination on: (insert date of 3rd Friday after filing)

Motion
Plaintiff respectfully requests that the Court appoint counsel to represent him/her. This action seeks relief under federal statutes protecting civil rights. This is not, however, an employment discrimination action brought under Title VII of the Civil Rights Act of 1964, 42 U.S.C.§2000e et seq. Financial Affidavit Has this Court previously granted you leave to proceed in forma pauperis?

No (if no, please complete in full and attach the financial affidavit)

Yes

If such was granted in a different case in this Court, please supply the case number.

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Previous Efforts to Retain an Attorney Describe briefly the efforts you have already made to retain an attorney. Indicate as accurately as possible how many attorneys you have contacted, and over what period of time. You need not identify the specific attorneys, and should not indicate the reasons they declined to represent you.

Merits of Claim Has the Equal Employment Opportunity Commission, the Washington State Human Rights Commission, or other state or federal agency officially determined whether there is reasonable cause to believe that the allegations of your complaint are true ? No Yes

If so, please identify the agency which made the finding, and the conclusion the agency reached: 14 15 16 17 18 19 20 21 22 23 24 25 If there has been no such finding in your favor by a government agency, you may attach a brief statement showing why your claim has merit. Do not include exhibits or other evidence. Your statement is incorporated in this application and is subscribed under oath.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 I have directed a copy of this entire Application, by mail or by personal service, to the attorney for each such party. Affidavit of Service The following is a list of all other parties, and their respective attorneys, who have appeared or answered in this action: Parties Attorneys Authorization for Release of Information to Members of the Civil Rights Screening Committee I hereby authorize the Equal Employment Opportunity Commission and the Washington State Human Rights Commission to furnish to members of the Federal civil Rights Case screening Committee and to any attorney subsequently selected by the Court to represent me with a copy of the files maintained by them in connection with my complaint of discrimination.

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I, plaintiff in this action, swear that I have read this entire Application, including any attachments, and the Complaint. In accordance with 28 U.S.C. §1746, I declare under penalty of perjury that the foregoing information is true and correct.

Signature of Plaintiff

Executed on this day:

Plaintiff's Name, Address and Phone Number: