Title: Approval of Form for Use by Clerks of the Circuit Courts - Rules Regulating the Florida Bar

State: florida

Issuer: Florida Supreme Court

Document:

1.  We have jurisdiction.  See art. V, § 2(a), Fla Const.
Supreme Court of Florida
____________
No. SC04-994
____________
IN RE: APPROVAL OF FORM FOR USE BY CLERKS OF 
THE CIRCUIT COURTS PURSUANT TO RULE 10-2.1(a) OF THE 
RULES REGULATING THE FLORIDA BAR.
[June 17, 2004]
CORRECTED OPINION
PER CURIAM.
In 2004, the Legislature amended section 27.52, Florida Statutes,
Determination of Indigence, to provide that the circuit court clerks shall use "a
form developed by the Supreme Court" to determine indigency for purposes of
appointing the public defender or a private attorney or "any other due process
services."  See Ch. 2004-265, § 9, at 14, Laws of Fla.1  Section 27.52 was also
amended to require the clerk of court to assist a person who appears before the
clerk and requests assistance in completing the form.  See id.  Chapter 2004-265,
Laws of Florida, has an effective date of July 1, 2004.  See id. § 109, at 81.
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In order to implement this legislation, the Court on its own motion hereby
approves and authorizes the publication of an affidavit of indigent status form for
use by the clerks of the circuit courts.  The Court approves this form pursuant to
rule 10-2.1(a) of the Rules Regulating the Florida Bar, which allows nonlawyers to
assist in the completion of legal forms approved by this Court.  However, only the
clerks of the circuit courts are authorized to assist individuals in completion of this
form.
Rule 10-2.1(a) requires the individual who assisted in preparation of the
form to provide a disclosure to the individual who sought assistance.  The Court
directs the circuit court clerks to this rule for language to be included in the
disclosure.  Because local procedures may vary from circuit to circuit, the chief
judge of each circuit is authorized to prepare instructions for the use of the
approved form. Instructions shall be filed with the clerk of court in the respective
circuit and with the clerk of this Court.  
The form as approved and authorized for publication is set forth in the
appendix to this opinion, effective July 1, 2004.  By approval of this form, the
Court expresses no opinion as to its correctness or applicability, or on the
substance of the new legislation. This opinion and the form discussed herein may 
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be accessed and downloaded from this Court's website at www.flcourts.org.
It is so ordered.
ANSTEAD, C.J., and WELLS, PARIENTE, LEWIS, QUINCE, CANTERO, and
BELL, JJ., concur.
NO MOTION FOR REHEARING WILL BE ALLOWED.
Original Proceeding - Rules Regulating The Florida Bar
Florida Supreme Court Approved Affidavit of Indigent Status (7/04)  
IN THE CIRCUIT/COUNTY COURT OF THE __________JUDICIAL CIRCUIT
IN AND FOR __________________COUNTY, FLORIDA
STATE OF FLORIDA vs. / IN THE INTEREST OF:
CASE NO.______________________________________
___________________________________
Defendant / Minor Child(ren) / Respondent
AFFIDAVIT OF INDIGENT STATUS 
Notice to Applicant:  The provision of a public defender/court-appointed lawyer is not free.  A judgment and lien may be imposed against all real or
personal property you own to pay for legal and other services provided on your behalf (or on behalf of the person for whom you are making this
application).  If the $40.00 application fee is not paid to the Clerk of the Court within 7 days, it will be added to any costs that may be assessed
against you at the conclusion of this case.  If you are a parent/guardian making this affidavit on behalf of a minor child or tax-dependent adult, the
information contained in this affidavit must include your income and assets.                           
1.   I have ______dependents.   (Do not include children not living at home and do not include working spouses.)
2.   I have take-home income of $________________ paid (   ) weekly  (   ) bi-weekly  (   )  semi-monthly (   ) monthly
     (Take-home income equals salary, wages, bonuses, commissions, allowances, overtime, tips and similar payments minus 
     deductions required by law and other court-ordered payments.)
3.   I have $_____________ in other annual income:  (Circle “Yes” and fill in the amount if you have this kind of income or circle
     “No” if you do not have this kind of income)
               Social Security benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes  $_________   
No
               Unemployment compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes  $_________   
No
               Union funds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes  $_________   
No
               Workers’ compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes  $_________  
No
               Retirement/pensions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes  $_________   
No
               Trusts or gifts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes  $_________  
No
               Veterans’ benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes  $_________  
No
               Other regular support from family members/spouse . . . . . . . . . . . . . . . . . . . . .  Yes  $_________  
No
               Rental income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes  $_________   
No
               Dividends or interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes  $_________  
No
               Other kinds of income not on the list . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes  $_________   
No     
4.
I have $_______________ in other assets.   (Circle “Yes” and fill in the value of the property or circle “No” if you do not have
this kind of property.)
              Cash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes  $_________   
No 
              Savings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes  $_________   
No
              Bank account(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes  $_________   
No
              Stocks and bonds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes  $_________   
No
              Certificates of deposit or money market accounts . . . . . . . . . . . . . . . . . . . . . . . .  Yes  $_________   
No
              Real estate (your ownership interest) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes  $_________   
No
              Boat(s) or aircraft (your ownership interest) . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes  $_________   
No
              Motor vehicle(s) (your ownership interest) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes  $_________   
No
              Life Insurance (cash value) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes  $_________
No
              Other valuable tangible property (like jewelry, coin collections, etc.) . . . . . . . .  Yes  $_________   
No
5.   I receive:  (Circle “Yes” or “No”)
              Temp. Assistance for Needy Families-Cash Assistance . . . . . . . . . . . . . . . . . . .  Yes
No   
              Poverty-related veterans’ benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes
No
              Supplemental Security Income (SSI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes
No
6.   I have been released on bail in the amount of $5,000 or more in this case . . . . . .  Yes
No
7.   I have a private lawyer in this case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  Yes
No
Florida Supreme Court Approved Affidavit of Indigent Status (7/04)  
8.   I expect to get or receive something of value at a later date (Like a tax refund, 
      payments from lawsuits, accrued vacation leave, a bonus, or inheritance) . . . . . . . . .  Yes  $_________  
No
**(Elect and complete either the notarized oath or the written declaration below pursuant to section 92.525, Florida
Statutes)
NOTARIZED OATH
I, _________________________ (full legal name), being first duly sworn, state under oath and under penalty of
perjury that the facts stated in the foregoing affidavit are true.  
                                                                                                                                                                   
          Signature of Applicant for Indigent Status                    Date Signed
                                                                     PRINT Full Legal Name ________________________________________  
                                                                     Address _____________________________________________________
                                                                     Driver’s License # or ID # ______________________________________
                                                                     Date of Birth  ________________________________________________
                                                                     Telephone                                                                                                          
WRITTEN DECLARATION
Under penalties of perjury, I declare that the facts stated in the foregoing affidavit are true.
                                                                    _____________________________________________________
           Signature of Applicant for Indigent Status                    Date Signed
                                                                PRINT Full Legal Name __________________________________  
                                                                Address ________________________________________________
                                                                Driver’s License # or ID # _________________________________
                                                                Date of Birth  ___________________________________________
      Telephone                                                                                             
**(If a clerk or deputy clerk helped you fill out this form, he or she must fill out the blank below.)
This form was completed with the assistance of                                                 , Clerk/Deputy Clerk.
DETERMINATION OF INDIGENT STATUS
Based on the information in this Affidavit, I have determined that the applicant is (   ) Indigent (   ) Not Indigent 
pursuant to section 27.52, F.S.
_________________________________________
________________________20__
                              ,Clerk of Court by Deputy Clerk 
                    Date