IN THE CIRCUIT/CO
UNTY COURT OF THE
_________________________ JUDICIAL CIRCUIT
IN AND FOR
________________ COUNTY, FLORIDA
STATE OF FLORIDA vs.
Defendant/Minor Child
CASE NO._________________________________
_________________________________________________
APPLICATION FOR CRIMINAL INDIGENT STATUS
☐ I AM SEEKING THE APPOINTMENT OF THE PUBLIC DEFENDER OR
☐ I HAVE A PRIVATE ATTORNE
Y 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: (Check “Yes” and fill in the amount if you have this kind of income,
otherwise check “No.”)
Social Security benefits .................. ☐Yes ☐No $_________________
Unemployment compensation ........ ☐Yes ☐No $_________________
Union funds ..............
.......................
☐Yes ☐No $_________________
Workers compensation ...............
....
☐Yes ☐No $_________________
Retirement/pensions ..............
.........
☐Yes ☐No $_________________
Trusts or gifts ..............
....................
☐Yes ☐No $_________________
Veterans’ benefit ..............
...............
.☐Yes ☐No $_________________
Child support or other regular support from
family members/spouse ................☐Yes ☐No $_________________
Rental income ...............
.................
..☐Yes ☐No $_________________
Dividends or interest ..............
.........
.☐Yes ☐No $_________________
Other kinds of income not on the list ☐Yes
☐No $
4. I have other assets: (Check “yes” and fill in the value of the property, otherwise check “No”)
Cash .....................................
. ☐Yes ☐No $_________________
Bank account(s) .............
................
. ☐Yes ☐No $_________________
Certificates of deposit or
money market accounts ........... ☐Yes ☐No $_________________
*Equity in motor vehicles .............
..
. ☐Yes ☐No $_________________
. ☐Yes ☐No $______________
Savings ................
................................ ☐Yes ☐No $
Stocks/bonds ....................................... ☐Yes ☐No $
*Equity in homestead real estate .......
. ☐Yes ☐No $
*Equity in non-homestead real estate . ☐Yes ☐No $
*include expectancy of an interest in such property
*Equity in boats/other tangible property
5. I have a total amount of liabilities and debts in the amount of $___________________.
6. I receive: (Check “Yes” or “No.”)
Temporary Assistance for Needy Families-
C
ash Assista
nce
Supplemental Securit
y Income (SSI) .......................
. ☐Yes ☐No
...
......................................... ☐Yes ☐No
Pover
ty- related veterans’ benefits ............................ ☐Yes ☐No
7. I have been released on b
ail 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.
________________________________________
Signed on
Year of Birth
Last f
our digits of Driver’s License or ID Number
Signature of applicant for indigent status
Print full legal name:
Address:
City, State, Zip:
Phone number:
E-mail Address:
CLERK 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, by Deputy Clerk
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. ________________________________________
Florida Supreme Court Form 3.984, Updated 5/1/19
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