Opinion ID: 1880836
Heading Depth: 1
Heading Rank: 6

Heading: affidavit of indigent status

Text: 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 .............................. Yes benefits ..................................... $____ No Unemployment ................................. Yes compensation ................................. $____ 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 ............ Yes members/spouse ............................... $____ 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 ........................................................ Yes account(s) .................................................. $____ No Stocks and ................................................. Yes bonds ...................................................... $____ No Certificates of deposit or money market .................... Yes accounts ................................................... $____ No Real estate (your ownership ................................ Yes interest) .................................................. $____ No Boat(s) or aircraft (your ownership ........................ Yes interest) .................................................. $____ No Motor vehicle(s) (your ownership ........................... Yes interest) .................................................. $____ No Life Insurance ............................................. Yes (cash value) ............................................... $____ No Other valuable tangible property (like jewelry, coin ....... Yes collections, etc.) ......................................... $____ 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 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 Date Signed Indigent Status 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 Date Signed Indigent Status 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 IN THE CIRCUIT/COUNTY COURT OF THE _______ JUDICIAL CIRCUIT IN AND FOR ________ COUNTY, FLORIDA STATE OF FLORIDA vs. CASE NO. ________________________ Defendant/Minor Child APPLICATION FOR CRIMINAL INDIGENT STATUS ____ 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 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/Other tangible property.................... Yes $ ____ No 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. CLERK'S DETERMINATION ____ Based on the information in this Application, I have determined the applicant to be () Indigent () Not Indigent pursuant to s. 27.52, F.S. ____ The Public Defender is hereby appointed to the case listed above until relieved by the Court. Dated this ____ day of ____, 20__. Clerk of the Circuit Court