Florida Rules of Criminal Procedure 3.984 April 6, 2020 The Florida Bar
IN THE CIRCUIT/COUNTY COURT OF THE FIFTH JUDICIAL CIRCUIT IN AND FOR LAKE 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: (Select “Yes” and fill in the amount if you have this kind of income, otherwise select “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: (Select “Yes” and fill in the value of the property, otherwise select “No”)
Cash ....................................................... Yes $ No
Bank account(s)....................................... Yes $ No
Certificates of deposit or money
market accounts ...................................
Yes $ No
* Equity in Motor vehicles/Boats/
Other tangible property ..................... Yes $ No
Savings ............................................................. Yes $ No
Stocks/bonds .................................................... Yes $ No
* Equity in Real estate
(excluding homestead) ............................... Yes $ No
* include expectancy of an interest in such property
5. I have a total amount of liabilities and debts in the amount of $ .
6. I receive: (Select “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 Section 27.52, Florida Statutes, commits a misdemeanor of
the first degree, punishable as provided in Section 775.082, Florida Statutes, or Section 775.083, Florida Statutes. I attest that the information I have provided on this application is
true and accurate.
Signed this day of , 20 .
Date of Birth
Signature of Applicant for Indigent Status
Last 4 Digits of 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 . Gary J. Cooney
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:
