Application For Determination Of Civil Indigent Status Form
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1IN THE CIRCUIT/COUNTY COURT OF THE SEVENTH JUDICIAL CIRCUIT
IN AND FOR VOLUSIA COUNTY, FLORIDA
CASE NO.
DIVISION
,
Plaintiff/Petitioner or In the Interest of
vs.
.
Defendant/Respondent
APPLICATION FOR DETERMINATION OF CIVIL INDIGENT STATUS
Notice to Applicant: If you do not qualify for civil indigency and you cannot afford to pay the filing fee, 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 $_________in 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
Veteran’s benefits
Yes $______________No
Unemployment compensation
Yes $__________ No
Child Support or other regular support
Union funds
Yes $__________ No
from family members/spouse Yes $______________ No
Worker’s compensation
Yes $__________ No
Rental income
Yes $______________ No
Retirement/pensions
Yes $__________ No
Dividends or interests
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 and bonds
Yes $______________ No
Certificates of deposit or
*Equity in real estate (excluding
money market account
Yes $__________ No
homestead)
Yes $______________ No
*Equity in Boats and other tangible
*Equity in motor vehicles
Yes $ _____________ No
property
Yes $__________ No
5. I have 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 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__________________________________________
________________________
Drivers License or ID Number
Address, P O Address, Street, City, State, Zip Code
Note: If applicant is determined by the clerk to be Not Indigent, you may seek judicial review by filing a petition to review.
CLERK’S DETERMINATION
Based on the information in this Application, I have determined the applicant to be_______ Indigent _______ Not indigent, according to
57.082, F.S.
DIANE M. MATOUSEK
Dated this _______ day of ________________, 20___.
By ____________________________
Deputy Clerk
This form was completed with the assistance of _______________________ Clerk/Deputy Clerk/Other.
CL-0326-0907
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