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.
Developed by the Florida Clerks of Court Operations Corporation
IN THE CIRCUIT/COUNTY COURT OF THE FOURTH
JUDICIAL CIRCUIT IN AND FOR CLAY 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 I
NDIGENCE 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 t
he 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 deducti
ons required by law and other court ordered
support payments)
3.
I have other income paid ( ) weekly ( ) bi-weekly ( ) semi-monthly ( ) monthly ( ) yearly: (fill in the amount if you have this kind of income, otherwise
check
“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 Ot
her 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.”)
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 *include expectancy of an interest in such property
*Equity in Mo
tor vehicles/Boats/…………… Yes $_________________ No
Other tangible property
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,
punishable as provided in s. 775.082, F.S. or s. 775.083, F.S.
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_____.
____________________________________________________________
Date of Birth ______________________ Signature of applicant for indigent status
Driver’s license or ID number______________________________
Print full legal name
Address
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 _____________.
This form was completed with the assistance of ___________________________________________
Clerk/Deputy Clerk/Other authorized person
TARA S. GREEN
Clerk of Circuit Court
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