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IN THE CIRCUIT COURT OF THE EIGHTEENTH JUDICIAL

CIRCUIT IN AND FOR SEMINOLE COUNTY, FLORIDA.

CASE NO.___________________________

IN RE: THE GUARDIAN ADVOCACY OF

____________________________________

Name of Person with a Developmental Disability

APPLICATION FOR DETERMINATION OF CIVIL INDIGENT STATUS

(Form G)

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

Page 1 of 2 of Form G

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

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