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IN THE CIRCUIT/COUNTY COURT OF THE SIXTH JUDICIAL CIRCUIT

IN AND FOR PINELLAS COUNTY, FLORIDA

_______________________

______________

CASE NO._________

_____________

Plaintiff/Petitioner or In the Interest Of

vs.

_______

_______________________________

Defendant//Respondent

APPLICATION FOR DETERMINATION OF CIVIL INDIGENT STATUS

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.

This fee shall not be charged for Dependency or Chapter 39 Termination of Parental Rights actions.

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

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(5), 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

Motor Vehicle* ........................................................ Yes $ __________ No

Boats*......................................................Yes $ __________ No

Non-homestead real property/real estate*.............. 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 total liabilities and debts of $_

_______ as follows: Motor Vehicle $____

______, Home $____

______,

Other 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

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

Driver’s License or ID Number

Print Full Legal Name ______________

_______