Page 1 of 2 of Form G IN THE CIRCUIT COURT, EIGHTEENTH JUDICIAL CIRCUIT IN AND FOR BREVARD COUNTY, FLORIDA CASE NO. IN RE: THE GUARDIAN ADVOCACY OF Name of Person with a Developmental Disability APPLICATION FOR DETERMINATION OF CIVIL INDIGENT STATUS (Form G ) Notice to Applicant: one - time administrative fee of $25.00. This fee shall not be charged for Dependency or Chapter 39 Termination of Parental Rights actions. 1. I have dependents. (Include only those persons you list on your U.S. Income tax return.) $ 2. I have a net income of $ paid ( ) weekly ( ) every two weeks ( ) semi - monthly ( ) monthly ( ) yearly ( ) other . (Net income is your total income including salary, wages, bonuses, commissions, allowances, over time, tips, and similar payments, minus deductions required by law and other court - ordered payments such as child support.) 3. I have other income paid ( ) weekly ( ) every two weeks ( ) semi - monthly ( ) monthly ( ) yearly ( ) other . (Circle Second Job ................................ ... Yes $ No ................................ .......... Yes $ No Social Security benefits Workers compensation ................................ .. Yes $ No Fo r you .......................... Yes $ No Income from absent family members .............. Yes $ No For child(ren) ................. Yes $ No Stocks/bonds ................................ ................. Yes $ No Unemployment compensation ........ Yes $ No Rental income ................................ ................ Yes $ No Union payments ............................. Yes $ No Dividends or interest ................................ ...... Yes $ No Retirement/pensions ...................... Yes $ No Other kinds of income not on the list .............. Yes $ No Trusts ................................ ............ Yes $ No Gifts ................................ ............................... Yes $ No I understand that I will be required to make payments for fees and costs to the clerk in accordance with 24757.082(5), Florida Statutes, as provided by law, although I may agree to pay more if I choose to do so. 4. I have other assets: Cash ................................ .............. Yes $ No Savings account ................................ ............. Yes $ No Bank account(s) ............................. Yes $ No Stocks/bonds ................................ ................. Yes $ No Certificates of deposit or Homestead Real Property* ............................. Yes $ No money market accounts ................. Yes $ No Motor Vehicle* ................................ ............... Yes $ No Boats* ................................ ............ Yes $ No Non - homestead real property/real estate* ...... Yes $ No *show loans on these assets in paragraph 5 Check one: I ( ) DO ( ) DO NOT expect to receive more assets in the near future. The asset is. 5. I have total liabilities and debts of $ as follows: Motor Vehicle $, Ho me $, Other Real Property $, Child Support paid direct $, Credit Cards $, Medical Bills $, Cost of medicines (monthly) $, Other $. 6. I have a private lawyer in this case o American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 of Form G A person who knowingly provides false information to the clerk or the court in seeking a determination of indigent status und er 24757.082, Fla. Stat. commits a misdemeanor of the first degree, punishable as provided in 247775.082, Fla. Stat. or 247775.083 , Fla. Stat. I attest 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 License or ID Number Print Full Legal Name Phone Number: Address, P O Address, Street, City, State, Zip Code Based on the information in this Application, I have determined the Applicant to be ( ) Indigent ( ) Not Indigent, according to 24757.082, Fla. Stat. Dated this day of , 20 . Clerk of the Circuit Court by This form was completed with the assistance of: Deputy Clerk for Scott Ellis, Clerk of Courts This form was completed with the assistance of , Clerk/Deputy Clerk/Other authorized person. APPLICANTS FOUND NOT TO BE INDIGENT MAY SEEK REVIEW BY A JUDGE BY ASKING FOR A HEARING TIME. THERE IS NO FEE FOR THIS REVIEW. American LegalNet, Inc. www.FormsWorkFlow.com