Application For Determination Of Civil Indigent Status - Marion County, Florida

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TH
IN THE CIRCUIT/COUNTY COURT OF THE 5
JUDICIAL CIRCUIT
IN AND FOR MARION COUNTY, FLORIDA
Case No.
Plaintiff/Petitioner
vs.
Defendant/Respondent
APPLICATION FOR DETERMINATION OF CIVIL INDIGENT STATUS
1.
I have ____ dependents. (Include only those persons you list on your U.S. Income tax return.)
Are you married? Yes
No
Does your Spouse Work? Yes
No
Annual Spouse Income $____________
2.
I have a net income of $____________ paid ( ) weekly ( ) every two weeks ( ) semi-monthly ( ) monthly ( ) yearly ( ) other.
(Net income is your total income including salary, wages, bonuses, commissions, allowances, overtime, tips, and similar payments, minus
deductions required by law and other court-ordered payments such as child support.)
3.
I have other income paid ( ) weekly ( ) every two weeks ( ) semi-monthly ( ) monthly ( ) yearly ( ) other $____________.
(Circle “Yes” and fill in the amount if you have this kind of income, otherwise, circle “No”.)
Second Job ........................................... Yes
$ ___________
No
Veterans benefits .............................................. Yes
$ ___________
No
Social Security Benefits ........................ Yes
$ ___________
No
Workers Compensation .................................... Yes
$ ___________
No
For you .......................................... Yes
$ ___________
No
Income from absent family members ............... Yes
$ ___________
No
For child(ren) ................................. Yes
$ ___________
No
Stocks / Bonds .................................................. Yes
$ ___________
No
Unemployment Compensation .............. Yes
$ ___________
No
Rental income ................................................... Yes
$ ___________
No
Union payments .................................... Yes
$ ___________
No
Dividends or interest ......................................... Yes
$ ___________
No
Retirement/pensions ............................. Yes
$ ___________
No
Other kinds of income not on the list ................ Yes
$ ___________
No
Trusts .................................................... Yes
$ ___________
No
Gifts .................................................................. Yes
$ ___________
No
I understand that I will be required to make payments for fees and costs to the clerk in accordance with §57.082(6), Florida Statutes, as provided by
law, although I may agree to pay more if I choose to do so.
4.
I have other assets: (Circle “yes” and fill in the value of the property, otherwise, circle “No”)
Cash ...................................................... Yes
$ ___________
No
Savings account ............................................... Yes
$ ___________
No
Bank account(s) .................................... Yes
$ ___________
No
Stocks / bonds .................................................. Yes
$ ___________
No
Certificates of deposit or
Homestead Real Property* ............................... Yes
$ ___________
No
money market accounts ........................ Yes
$ ___________
No
(EXCLUDE VALUE OF HOMESTEAD)
Motor Vehicle* ....................................... Yes
$ ___________
No
Non-homestead real property / real estate ....... Yes
$ ___________
No
Boats* .................................................... Yes
$ ___________
No
Other assets* .................................................... Yes
$ ___________
No
*Show loans on these assets in paragraph 5
Check one: I ( ) DO ( ) DO NOT expect to receive more assets in the near future. The asset is _____________________________.
5.
I have a total amount of liabilities and debts of $________________ as follows:
Motor Vehicle $ ____________ ,
Home $ ___________ ,
Boat $ ______________ ,
Non-homestead Real Property $ _______________ ,
Child Support paid direct $ _______________ ,
Credit Cards $ ______________ ,
Medical Bills $ _______________ ,
Cost of medicines
(monthly) $ ____________ ,
OTHER $ ____________ .
6.
I have a private lawyer in this case ................. Yes
No
(Circle one.)
A person who knowingly provides false information to the clerk or the court in seeking a determination of indigent status under F.S. 57.082 commits a
misdemeanor of the first degree, punishable as provided in s. 775.082 or s. 775.083. 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 Legal Name ___________________________________________
Driver’s License or ID Number ___________________________
Phone Number: ________________________________________________
Address, P.O. Address, Street, City, State, Zip Code ____________________________________________________________________________
This form was completed with the assistance of:
______________________________________________________________
Clerk / Deputy Clerk / Other authorized person
CLERK’S DETERMINATION
Based on the information in this Application, I have determined the applicant to be ( ) Indigent ( ) Not Indigent, according to F.S. 57.082.
Date this _____ day of ____________ , 20 ___ .
Clerk of the Circuit Court
By________________________________________, Deputy Clerk
APPLICANTS FOUND NOT TO BE INDIGENT MAY SEEK REVIEW BY A JUDGE BY ASKING FOR A HEARING TIME.
THERE IS NO FEE FOR THIS REVIEW.
Sign here if you want the judge to review the clerk’s decision ____________________________________________________________.
eff 07/14/09

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