Affidavit Form Of Indigence Pursuant To Section 57.085, Florida Statutes - Alachua County, Florida

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THE CIRCUIT COURT OF THE EIGHTH JUDICIAL CIRCUIT
IN AND FOR ALACHUA COUNTY, FLORIDA
,
Plaintiff/Petitioner,
vs.
Case No: _______________________
,
Defendant/Respondent.
AFFIDAVIT OF INDIGENCE PURSUANT TO SECTION 57.085, FLORIDA STATUTES
STATE OF FLORIDA, COUNTY OF _______________________
BEFORE ME the undersigned personally appeared, was duly sworn, and says:
1. My full name is
My address is
My Department of Corrections inmate number is
.
2. My present income is $
and the nature of this income is
3. My total assets are valued at $___________, A complete list of my assets on the date of this affidavit are:
(a) The amount of cash held by me and the balance of any checking, savings, money market, or trust
accounts held by me is ________________________________________________$_______________
(b) All tangible and intangible property worth more than $100, including, but not limited to, vehicles, stock,
bonds, notes or negotiable securities, description of each is _____________________ $___________
All real property (description and location) is ______________________
$ ____________
4. The names and ages of my dependents for whom I pay child support are:
.
5. The following is a complete list of debts owed by me and the name of and amount owed to each creditor:
TOTAL DEBTS: $___________
6. My monthly expenses are:
7. I
have /
have not (mark one) been adjudicated indigent under s. 57.085, Florida Statutes, certified
indigent under s. 57.081, Florida Statutes, or authorized to proceed as an indigent under 28 U.S.C. s. 1915 by
a federal court more than twice in the 3 years preceding the filing of this action. (If the affiant has been so
adjudicated, affiant must seek leave of court to pursue a new suit).
8. I am presently unable to pay court costs and fees.
9. I have attached a photocopy of my prisoner’s trust account record for the preceding 6 months or for the
length of my incarceration, whichever period is shorter.
Under penalty of perjury, I swear or affirm that all statements in this affidavit are true and complete.
________________________________
Affiant
This Affidavit of Indigence was sworn to and subscribed before me on ________________________20___, by
_______________________________________________ who is personally known to me or who produced
_____________________________ as identification and who
did /
did not take an oath.
(SEAL)
_______________________________
My Commission Expires:
Notary Public
10/2/15 jas

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