Application For Determination Of Civil Indigent Status

IN THE CIRCUIT/COUNTY COURT OF THE ------------------ JUDICIAL CIRCUIT IN AND FOR ---------------- COUNTY, FLORIDA _____________________________________ CASE NO.______________________________________ Plaintiff/Petitioner or In the Interest Of vs. ______________________________________ Defendant//Respondent APPLICATION FOR DETERMINATIN OF CIVO IL INDIGENT STATUS Notice to Applicant: If you qualify for civil indigence you must enroll in the Clerks Office payment plan and pay a one-timf $25.e ad00. ministrative fee o 1. I have ______d ependents. (Do not include children not living at home and do not include a working spouse or yourself.) 2. I have a take home i ncome of $______________ paid ( ) weekly ( ) bi-weekly ( ) semi-m_onthly ( ) monthly ( ) yearly (Take home income equals salary, wages, bonuses, commissions, allowances, overtime, tips and similar paymentminus s,deduct ions required by law and other court ordered support payments) 3. I have other income paid ( ) weekly ( ) bi-weekly ( ) semi-monthly ( ) mont: hly(Circle ( ) yearly Yes and fill in the amount if you have this kind of income, otherwise circle No) Social Security benefits.. Yes $__________________ No Veterans benefits Yes $__________________ No Unemployment compensation.. Yes $__________________ No Child support or other regular support Union Funds. Yes $__________________ No from family members/spouse. Yes $_____________ No _____ Workers compensation.. Yes $__________________ No Rental income. Yes $__________________ No Retirement/pensions... Yes $__________________ No Dividends or interest. Yes $__________________ No Trusts or gifts Yes $__________________ No Other kinds of income not on the list... Yes $__________________ No 4. I have other assets: (Circle yes and fill in the value of the property, otherwise circle No) Cash. Yes $__________________ No Savings Yes $__________________ No Bank account(s). Yes $__________________ No Stocks/bonds.. Yes $__________________ No Certificates of deposit or quity in *E Real estate (excluding homestead) Yes $__________________ No money market accounts. Yes $__________________ No lude expectancy *incof an interest in such property *Equity in Motor vehicles/Boats/ Other tangible property Yes $_________________ No 5. I have a total amount of liabili atind debtess in the amount of $__________________, 6. I have a private lawyer in this case.. Yes No A person who knowingly provides false information to the clerthek or co urt in seeking a determination of indigent status un s.der 57.082, F.S. commits a misdemeanor of the first degree, punishable as provided in s.775.082, F.S. or s. 775.083, F.I attS. est that the information I have provided on this application is true and accurate to the best of my knowledge. Signed this _________ day of _______________, 20____. ________________ Signature of Applicant for Indigent Status Date of Birth Print Full Legal Name__________________________________________ ________________________ ____________________________________________ ________________ Drivers License or ID Number Address, P O Address, Street, City, State, Zip Code Phone Number: ____________________________________________ NOTICE: If the applicant is determined by the clerk to be Not Indigent, you may seek judicial review by filing a petition with the court. CLERKS DETERMINATION Based on the information in this Application, I have determinedapp the licant to be ( ) Indigent ( ) Not Indigenordt, accing to s. 57.082, F.S. Dated this _________ day of ______________, 20 ____. C lerk of the Circuit court This form was completed with the assistance of _______________Clerk/Deputy Clerk/Other authorized person. Final approval by The Florida Supreme Court on June 30, 2005. American LegalNet, Inc. www.USCourtForms.com