Application For Criminal Indigent Status Form
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1IN THE CIRCUIT/COUNTY COURT OF THE ____________________ JUDICIAL CIRCUIT
IN AND FOR _________________ COUNTY, FLORIDA
STATE OF FLORIDA vs.
CASE NO.______________________________________
______________________________________
Defendant/Minor Child
APPLICATION FOR CRIMINAL INDIGENT STATUS
____ I AM SEEKING THE APPOINTMENT OF THE PUBLIC DEFENDER
OR
____ I HAVE A PRIVATE ATTORNEY OR AM SELF-REPRESENTED AND SEEK DETERMINATION OF INDIGENCE STATUS FOR COSTS
Notice to Applicant: The provision of a public defender/court appointed lawyer and costs/due process services are not free. A judgment and lien may be imposed against all real or
personal property you own to pay for legal and other services provided on your behalf or on behalf of the person for whom you are making this application. There is a $50.00 fee for each
application filed. If the application fee is not paid to the Clerk of the Court within 7 days, it will be added to any costs that may be assessed against you at the conclusion of this case. If
you are a parent/guardian making this affidavit on behalf of a minor or tax-dependent adult, the information contained in this application must include your income and assets.
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 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
Veterans’ benefit……………………….... Yes $_________________
No
Unemployment compensation…………….. Yes $_________________
No
Child support or other regular support
Union Funds…………………………………. Yes $_________________
No
from family members/spouse……… Yes $_________________
No
Workers compensation…………………….. Yes $_________________
No
Rental income…………………………… Yes $_________________
No
Retirement/pensions………………..……… Yes $_________________
No
Dividends or interest…………………….. 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.” Use the back of this form to provide additional information.)
Cash…………………………………………. Yes $_________________
No
Savings………………………………………… Yes $_________________
No
Bank account(s)…………………………….. Yes $_________________
No
Stocks/bonds………………………………….. Yes $_________________
No
Certificates of deposit or
*Equity in Real estate (excluding homestead) Yes $_________________
No
money market accounts…………….. Yes $_________________
No
*Equity means value minus loans. Also list
*Equity in Motor Vehicles/Boats/
any expectancy in an interest in such property.
Other tangible property……………… Yes $_________________
No
List the address of this property:
List the year/make/model and tag #: ________________________________
Address
_________________________________________
City, State, Zip
_________________________________________
County of Residence _________________________________________
5. I have a total amount of liabilities and debts in the amount of $___________________,
6. I receive: (Circle “Yes” or “No”)
Temporary Assistance for Needy Families-Cash Assistance…………………………………………………………………………………..………….….
Yes
No
Poverty-related veterans’ benefits….……………………………………………………………………………………………………………………..……..
Yes
No
Supplemental Security Income (SSI)………………………………………………………………………………………………………………………….….
Yes
No
7. I have been released on bail in the amount of $________________.
Cash _____ Surety _____
Posted by: Self _____ Family _____
Other ______
A person who knowingly provides false information to the clerk or the court in seeking a determination of indigent status under s. 27.52, F.S., commits a misdemeanor of the first degree,
I attest that the information I have provided on this Application is true and accurate to the best of my
punishable as provided in s. 775.082, F.S., or s. 775.083, F.S.
knowledge.
Signed this _________ day of _______________, 20____.
Signature of Applicant for Indigent Status
Date of Birth ________________________________
Print Full Legal Name
____________________________________
Address
__________________________________
Driver’s license or ID number _________________
City, State, Zip
__________________________________
Phone number
__________________________________
CLERK’S DETERMINATION
_______Based on the information in this Application, I have determined the applicant to be ( ) Indigent ( ) Not Indigent
_______The Public Defender is hereby appointed to the case listed above until relieved by the Court.
Dated this _________ day of ______________, 20 ____.
_____________________________________
Clerk of the Circuit Court
This form was completed with the assistance of
_____________________________________
Clerk/Deputy Clerk/Other authorized person
APPLICANTS FOUND NOT INDIGENT MAY SEEK REVIEW BY ASKING FOR A HEARING TIME. Sign here if you want the judge to
review the clerk’s decision of not indigent. _____________________________________________________
06/18/10
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