IN THE DISTRICT COURT OF APPEAL OF THE STATE OF FLORIDA FOURTH DISTRICT 1525 PALM BEACH LAKES BLVD. WEST PALM BEACH, FL 33401 ___________________________________, Petitioner/Appellant, v. CASE NO. _________________ ___________________________________, Respondent/Appellee. FINANCIAL AFFIDAVIT OF INDIGENCY AS REQUIRED BY SECTION 57.081 OR 57.085(2), FLORIDA STATUTES (1997) Petitioner/Appellant ___________________________________, in propria persona, respectfully requests a Clerk's Certificate of Indigency permitting him/her to proceed in forma pauperis. In support hereof petitioner/appellant submits a financial affidavit of indigency as required by section 57.081 or 57.085(2), Florida Statutes (1997). I, _________________________________, inmate number _________________, hereby depose and say that I am unable to pay court costs and fees and submit the following information for review: AGE: ____ DATE OF BIRTH: _________________ MARITAL STATUS: Married___ Separated___ Divorced ___ Single ___ LIST DEPENDENTS, THEIR NAMES, AND AGES: ______________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ FINANCIAL CONDITION: Affiant's Gross Income: Weekly $__________ Bi-weekly $__________ Monthly $__________ Spouse's Gross Income: Weekly $__________ Bi-weekly $__________ Monthly $__________ Own Home: Yes ___ No ___ Monthly Mortgage Payments $___________________________ Value of Real Property Owned $___________________________________________________ Own Automobile: Yes ___ No ___ Monthly Payments $_______________________________ Value of Automobile: $__________ Year/Make: _____________________________________ Value of Personal Property Owned (boats, furniture, stocks, jewelry, etc.) List all tangible property with a value over $100.00 Item $ Value ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Value of Personal Debts (money owed): ______________________________________________________________________________ ______________________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com ______________________________________________________________________________ ______________________________________________________________________________ List debtor and the amount owed to each debtor: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Petitioner/Appellant's monthly expenses: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Amount of cash held by petitioner/appellant: $_________________________________________ Balance of checking account: $_____________________________________________________ Balance of savings account: $______________________________________________________ Amount held in money-market (stocks, bonds, other intangible personal property): $___________ ______________________________________________________________________________ Amount currently held in the petitioner/appellant's inmate trust account: $___________________ Attach photocopy of inmate's trust account records for the proceeding six (6) months or for petitioner/appellant's incarceration, whichever period is shorter. Are you presently employed in an inmate work program within the Department of Corrections? Yes _____ No _____ If the answer if "yes," complete the following: Wages earned: $__________ Name and address of employer: ___________________________________________________________ _____________________________________________________________________________________ If the answer is "no," state the date of your last employment and the salary and wages earned per month. Date: _______________ Wages earned: $_______________ Are you presently employed in a work release program? Yes ___ No ___ If the answer is "yes," complete the following: Wages earned: $_______________ Name and address of employer: ___________________________________________________________ _____________________________________________________________________________________ If the answer is "no," state the date of your last employment and the salary and wages earned per month. Date: _______________ Wages earned: $_______________ I certify that I have ___ have not ___ been adjudicated indigent under section 57.081. 57.085 or 28 U.S.C. 1915. If your answer is "yes" and it occurred twice in the preceding three (3) years, you are required to list each suit, action, claim, proceeding, or appeal which you have intervened in any court or other adjudicatory forum in the preceding five years and a copy of each complaint, petition, or other document purporting to commence a lawsuit and a record of disposition of the proceeding(s): 1.___________________________________________________________________________________ 2.___________________________________________________________________________________ 3.___________________________________________________________________________________ Attach extra sheet(s) if necessary. American LegalNet, Inc. www.FormsWorkflow.com Complete number 1 OR 2 of the following: 1. Under penalties or perjury, I declare that I have read the foregoing (document) and that the facts stated in it are true. (Section 92.525(2) Fla. Stat. (1995)) Dated this _____ day of _______________, 20_____, at _________________________, Florida. ____________________________________ Signature of Petitioner/Appellant (Original signature required) Address: _______________________________ _______________________________ _______________________________ -or- 2. Sworn to and subscribed before me this _____ day of _______________, 20_____. _______________________________ Notary Public, State of Florida My Commission Expires: _________________ IN THE DISTRICT COURT OF APPEAL OF THE STATE OF FLORIDA FOURTH DISTRICT, 1525 PALM BEACH LAKES BLVD. WEST PALM BEACH, FL 33401 ___________________________________, Petitioner/Appellant, v. CASE NO. _________________ ___________________________________, Respondent/Appellee. CERTIFICATE REGARDING INMATE ACCOUNT (Department of Corrections' Representative: Please sign applicable portion of Certificiate.) American LegalNet, Inc. www.FormsWorkflow.com I certify that petitioner/appellant does not have a bank account within the institution in which he is confined. ___________________________________________ Signature of Authorized Officer of Institution Name: _____________________________________ Institution: __________________________________ Address: ____________________________________ ____________________________________________ -orI certify that the petitioner has the sum of $_______________ on account to his credit at _______ ________________________________________ Correctional Institution where he is confined. I further certify that during the last six months the petitioner's average daily balance was $_______________. (Attach a statement of the inmate's bank account for last six months) ___________________________________________ Signature of Authorized Officer of Institution Name: _____________________________________ Institution: __________________________________ Address: ____________________________________ ____________________________________________ American LegalNet, Inc. www.FormsWorkflow.com