Application For Determination Of Civil Indigent Status Form

IN THE CIRCUIT/COUNTY COURT OF THE SIXTH JUDICIAL CIRCUIT

IN AND FOR PASCO COUNTY, FLORIDA

In the Interest of

Case Number:

SPN:

APPLICATION FOR DETERMINATION OF CIVIL INDIGENT STATUS

(Dependency and Termination of Parental Rights cases)

Notice to Applicant: You must pay an application fee of $50.00 and if you qualify for civil indigence you must enroll in the Clerk and Comptroller’s Office payment plan.

1. I have ______dependents.

Are you married? Yes No

2. I have income of $_______________ paid ( ) weekly ( ) every two weeks ( ) 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 ( ) monthly ( ) yearly ( ) other

(Circle “Yes” and fill in the amount if you have this kind of income, otherwise circle “No”)

Second Job

Yes $________ No

Trust

Yes $ ________ No

Stocks/bonds

Yes $________ No

Social Security Benefits

Gifts

Yes $ ________ No

Rental Income

Yes $________ No

For you

Yes $________ No

Veteran’s Benefit

Yes $ ________ No

Dividends/Income

Yes $________ No

For child(ren)

Yes $________ No

Workers’ Compensation

Yes $ ________ No

Other kinds of

Unemployment Compensation

Yes $________ No

Income from absent.

interest not on list Yes $________ No

Union Payments

Yes $________ No

family members

Yes $ ________ No

Retirement/Pensions

Yes $________ No

4. I have 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

Yes $________ No

Money market fund

Yes $________ No

Car*

Yes $________ No

Homestead Real property*

Yes $________ No

Boat

Yes $________ No

Non-homestead real property / real estate*

Yes $________ No

*Show loans on these assets in paragraph 5. You may have $2500 in equity in property and $5000 equity in a car and still be indigent.

I expect to have more of these items in the near future. Yes No

If yes, that property is __________________________________________________________________ .

5. My total liabilities and debts are as follows:

Home

$____________

Car

$____________

Credit cards $____________

Loans

$____________

Medical Bills

$_______________

Non-homestead real property $_____________________

Total

$_______________

6. It would be a substantial hardship to pay any fees or costs in this matter because:

___________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________

7. Cost of medicines (monthly) $_____________________.

A person who knowingly provides false information to the Clerk and Comptroller or the court in seeking a determination of indigent status under s. 57.082, F.S., commits a misdemeanor of the first

I attest that the information I have provided on this application is true and accurate to the best of my

degree, punishable as provided in s. 775.082, F.S. or 775.083, F.S.

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

____________________________________________________

City, State, Zip

____________________________________________________