Opinion ID: 1880836
Heading Depth: 1
Heading Rank: 4

Heading: application for determination of civil indigent status

Text: 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' benefit................... Yes $ ____ No Unemployment compensation ...... Yes $ ____ No Child support or other regular Union Funds .................... Yes $ ____ No 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 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__. ________________________________________ _______________________ 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 by filing a petition with the court.