Fill and Sign the In the Countycircuit Court Judicial Circuit I N and for Form

Final approval by The Florida Supreme Court on June 30, 2005. IN THE CIRCUIT/COUNTY COURT OF THE ------------------ JUDICIAL CIRCUIT IN AND FOR ---------------- COUNTY, FLORIDA _____________________________________ CASE NO.______________________________________Plaintiff/Petitioner or In the Interest Ofvs.______________________________________Defendant//Respondent 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 $25.00.1. I have ______dependents. (Do not include children not living at home and do not include a working spouse or yourself.)2. I have a take home income of $_______________ paid ( ) weekly ( ) bi-weekly ( ) semi-monthly ( ) monthly ( ) yearly(Take home income equals salary, wages, bonuses, commissions, allowances, overtime, tips and similar payments, minus deductions required by law and other court ordered support payments)3. I have other income paid ( ) weekly ( ) bi-weekly ( ) semi-monthly ( ) monthly ( ) yearly: (Circle “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 $__________________ NoWorkers compensation…………………….. Yes $__________________ No Rental income…………………………….Yes $__________________ NoRetirement/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 $__________________ NoBank account(s)……………………………. Yes $__________________No Stocks/bonds…………………………………..Yes $__________________ NoCertificates of deposit or *Equity in Real estate (excluding homestead) Yes $__________________No money market accounts……………. Yes $__________________ No*include expectancy of an interest in such property *Equity in Motor vehicles/Boats/ Other tangible property……………… Yes $_________________ No 5. I have a total amount of liabilities and debts in the amount of $__________________,6. I have a private lawyer in this case……………………………………………………………………………………………………………………..…………………Yes NoA 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____.________________ Signature of Applicant for Indigent StatusDate of Birth Print Full Legal Name______________________________________________________________________________________________________________________________Drivers License or ID NumberAddress, 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. CLERK’S DETERMINATION Final approval by The Florida Supreme Court on June 30, 2005.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 This form was completed with the assistance of _______________Clerk/Deputy Clerk/Other authorized person.