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Form G - Application For Determination Of Civil Indigent Status - Seminole County, Florida Page 2

A person who knowingly provides false information to the clerk or the court in seeking a determination of indigent status under §57.082, Fla.

Stat. commits a misdemeanor of the first degree, punishable as provided in §775.082, Fla. Stat. or §775.083, Fla. Stat. 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

CLERK’S DETERMINATION

Based on the information in this Application, I have determined the Applicant to be ( ) Indigent ( ) Not Indigent, according to

§57.082, Fla. Stat.

Dated this _________ day of ______________, 20 ____.

Clerk of the Circuit Court by

This form was completed with the assistance of: __________________________________________________

Clerk/Deputy Clerk/Other authorized person.

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 __________________________________________

Page 2 of 2 of Form G

Form G - Application For Determination Of Civil Indigent Status - Seminole County, Florida Page 2