Fillable IN THE CIRCUIT/COUNTY COURT OF THE SIXTH JUDICIAL (Pinellas County Clerk of the Circuit Court and Comptroller)

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IN THE CIRCUIT/COUNTY COURT OF THE SIXTH JUDICIAL (Pinellas County Clerk of the Circuit Court and Comptroller)

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CRDI – IF INDIGENT / CRDN – IF NOT INDIGENT
Per Admin Order 2005-40 – Ct Determination of Indigence
7/2005
IN THE CIRCUIT/COUNTY COURT OF THE SIXTH JUDICIAL CIRCUIT
IN AND FOR PINELLAS COUNTY, FLORIDA
_____________________________________ CASE NO.__________________
Plaintiff/Petitioner or In the Interest Of
vs.
_______ _______________________________
Defendant//Respondent
Petition for Court Review of Clerk’s Determination of
Non-Indigence for Appointment of Counsel and Relief
From Prepayment of Costs for Civil Litigants
1.
{To be completed by the Clerk} The Clerk of Court has determined that you are not
indigent because:
You own, have equity, or have the expectancy of an interest in personal or
real property with a net equity value of at least $2,500, excluding your
homestead and one vehicle not exceeding $5,000 in value.
Your income exceeds 200% of the federal poverty guidelines.
2.
{To be completed by the Plaintiff/Defendant if review requested} You may request that
the Court review the Clerk of Court’s denial of indigent status by filing a petition with the
Court. You will not be charged a filing fee to file this petition. If you wish to file such a
petition, please indicate below:
I hereby request review by the Court of the denial of indigent status.
Reason for requesting Court review:
I am unable to pay for the services of an attorney or other fees and costs without
substantial hardship to my family because
Explain other reasons:
3.
Are you represented by a private attorney? Yes______ No ______ (if no, skip to the
signature line)
When did you retain private counsel? _____ _
Is private counsel representing you for free? Yes (if yes, skip to signature line)
No _______
What is the amount of attorney’s fees and who is paying them?
CRDI – IF INDIGENT / CRDN – IF NOT INDIGENT
Per Admin Order 2005-40 – Ct Determination of Indigence
7/2005
Under penalties of perjury, I declare the facts stated above are true.
Applicant
PRINT Full Legal Name:
Address:
Driver’s License # or ID #
Date of Birth
Telephone:
If a clerk or deputy clerk helped you fill out this form, he or she must fill out the blank below.
This form was completed with the assistance
of
Clerk/Deputy Clerk.
If a non-lawyer helped you fill out this form he/she must fill in the blanks below:
I (full legal name and trade name of non-lawyer)
a non-lawyer, located at (street)
(city)
(state)
(phone)
helped
fill out this form.
COURT’S FINAL DETERMINATION OF INDIGENT STATUS
Applicant is Indigent
Plaintiff/Defendant is not
indigent
Appoint Counsel
.
Waive Prepayment of Fees and Costs
Date:
Judge
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IN THE CIRCUITCOUNTY COURT OF THE SIXTH JUDICIAL (Pinellas County Clerk of the Circuit Court and Comptroller)

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Completed 10 February 2021

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