IN THE CIRCUIT/COUNTY COURT OF THE ------------------ JUDICIAL CIRCUIT IN AND FOR ---------------- COUNTY, FLORIDA _____________________________________ Plaintiff/Petitioner or In the Interest Of vs. ______________________________________ Defendant//Respondent CASE NO.______________________ APPLICATION FOR DETERMINATION OF CIVIL INDIGENT STATUS Notice to Applicant: If you qualify for civil indigence you must enroll in the clerk’s office payment plan and pay a 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.) Are you Married?...Yes….No Does your Spouse Work?...Yes….No Annual Spouse Income? $_____________ 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, overtime, 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 “Yes” and fill in the amount if you have this kind of income, otherwise circle “No”) Second Job .............................................Yes $ Social Security benefits For you....................................Yes $ For child(ren) ..........................Yes $ Unemployment compensation ................Yes $ Union payments ......................................Yes $ Retirement/pensions ...............................Yes $ Trusts ......................................................Yes $ __________ No __________ __________ __________ __________ __________ __________ No No No No No No Veterans’ benefits....................................................Yes $ Workers compensation............................................Yes $ Income from absent family members ......................Yes $ Stocks/bonds ...........................................................Yes $ Rental income..........................................................Yes $ Dividends or interest................................................Yes $ Other kinds of income not on the list .......................Yes $ Gifts .........................................................................Yes $ __________ No __________ No __________ No __________ No __________ No __________ No __________ No __________ No I understand that I will be required to make payments for fees and costs to the clerk in accordance with §57.082(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: (Circle “yes” and fill in the value of the property, otherwise circle “No”) Cash........................................................Yes $ __________ No Savings account ......................................................Yes $ Bank account(s) ......................................Yes $ __________ No Stocks/bonds ...........................................................Yes $ Certificates of deposit or Homestead Real Property*......................................Yes $ money market accounts..........................Yes $ __________ No Motor Vehicle* .........................................................Yes $ Boats* .....................................................Yes $ __________ No Non-homestead real property/real estate* ..............Yes $ __________ No __________ No __________ No __________ No __________ 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 $__________, Home $__________, 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………… Yes No A person who knowingly provides false information to the clerk or the court in seeking a determination of indigent status under s. 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.S. 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____. ___________ ________________________ Date of Birth Driver’s License or ID Number ____________________________________ Signature of Applicant for Indigent Status Print Full Legal Name _____________________ Phone Number: __________________________ _______________________________________ Address, P O Address, Street, City, State, Zip Code American LegalNet, Inc. www.FormsWorkflow.com CLERK’S DETERMINATION Based on the information in this Application, I have determined the applicant to be ( ) Indigent ( ) Not Indigent, according to s. 57.082, F.S. Dated this _________ day of ______________, 20 ____. Clerk of the Circuit Court by 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. Sign here if you want the judge to review the clerk’s decision __________________________________________ American LegalNet, Inc. www.FormsWorkflow.com