Application For Determination Of Civil Indigent Status Form - Alachua County, Florida

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IN THE CIRCUIT/COUNTY COURT OF THE EIGHTH JUDICIAL CIRCUIT
IN AND FOR ALACHUA 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, the filing and summons fees are waived; other costs and fees are not waived
.
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 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
Other assets* .......................................................... Yes $ __________ No
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 $__________, 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
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 ___________________________________
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 s. 57.082, F.S.
Dated this _________ day of ______________, 20 ____.
J.K. “BUDDY” IRBY
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 ________________________________________________________________________
07/01/2012

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