Opinion ID: 1880836
Heading Depth: 1
Heading Rank: 2

Heading: application for criminal indigent status

Text: ____ I AM SEEKING THE APPOINTMENT OF THE PUBLIC DEFENDER OR ____ I HAVE A PRIVATE ATTORNEY OR AM SELF-REPRESENTED AND SEEK DETERMINATION OF INDIGENCE STATUS FOR COSTS Notice to Applicant: The provision of a public defender/court appointed lawyer and costs/due process services are 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. There is a $40.00 fee for each application filed. If the 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 or tax-dependent adult, the information contained in this application must include your income and assets. 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' benefit ........... Yes $ ____ No Unemployment compensation ... Yes $ ____ No Child support or other Union Funds ................. Yes $ ____ No regular support from family members/spouse ........... Yes $ ____ No Workers compensation ........ Yes $ ____ No Rental income .............. Yes $ ____ No Retirement/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 $ ____ No Bank account(s) ....................... Yes $ ____ No Stocks/bonds ............... Yes $ ____ No Certificates of deposit or money Equity in Real estate market accounts ....................... Yes $ ____ No (excluding homestead) ...... Yes $ ____ No Equity in Motor vehicles/Boats/ ...... Yes $ ____ No Other tangible property include expectancy of an interest in such property 5. I have a total amount of liabilities and debts in the amount of $_____, 6. I receive: (Circle Yes or No) Temporary Assistance for Needy Families-Cash Assistance ................ Yes No Poverty- related veterans' benefits .................................... Yes No Supplemental Security Income (SSI) ..................................... Yes No 7. I have been released on bail in the amount of $____. Cash ______ Surety ____ Posted by: Self ____ Family ____ Other ____ A person who knowingly provides false information to the clerk or the court in seeking a determination of indigent status under s. 27.52, 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 Status Date of Birth Print Full Name ___________________________ ___________________________ ___________________________________________ Drivers License or ID Number Address, 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 at your next scheduled court appearance.