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IN THE CIRCUIT COURT OF THE [judNo] JUDICIAL CIRCUIT

IN AND FOR [county] COUNTY, FLORIDA

CASE NO.
Plaintiff/Petitioner or in the Interest of
vs.
Defendant/Respondent

APPLICATION FOR DETERMINATION OF CIVIL INDIGENT STATUS

Notice to applicant: if you qualify for civil indigence, the filing and summons are waived; other costs and fees are not waived.

I have	dependents. (include only those persons you list on your US Income tax return.)
Are you Married?	Yes	No	Does your spouse work?	Annual Spouse Income?	$

I have a net income of $	paid ( ) weekly ( ) every two weeks ( ) semi-monthly ( ) monthly ( ) yearly ( ) other
(Net income is your total income including salary, wages, bonuses, commissions, allowances, overtime, tips and similar payments, minus deductions required by law and other court-ordered payments such as child support.)

I have other income paid	( ) weekly ( ) every two weeks ( ) semi-monthly ( ) monthly ( ) yearly ( ) other
(Circle “Yes” and fill in the amount if you have this kind of income, otherwise circle “No”)
Second Job	Yes $	No	Veterans’ benefits	Yes $	No
Social Security benefits	Workers compensation	Yes $	No
For you	Yes $	No	Income from absent family members	Yes $	No
For child(ren)	Yes $	No	Stocks/bonds	Yes $	No
Unemployment compensation	Yes $	No	Rental income	Yes $	No
Union payments	Yes $	No	Dividends or interest	Yes $	No
Retirement/pensions	Yes $	No	Other kinds of income not on the list	Yes $	No
Trusts	Yes $	No	Gifts	Yes $	No

I understand that I will be required to make payments for fees and costs to the clerk in accordance with §57.082(5), Florida Statutes, as provided by law, although I may agree to pay more if I choose to do so.

I have other assets:	(Circle “Yes” and fill in the value of the property, otherwise circle “No”)
Cash	Yes $	No	Savings account	Yes $	No
Bank account(s)	Yes $	No	Stocks/bonds	Yes $	No
Certificates of deposit or money market accounts	Homestead Real Property*	Yes $	No
Yes $	No	Motor Vehicle*	Yes $	No
Boats*	Yes $	No	Non-homestead real property/real estate*	Yes $	No
Other assets*	Yes $	No

*show loans on these assets in paragraph 5.

Check one: I ( ) DO ( ) DO NOT expect to receive more assets in the near future. The asset is
I have total liabilities, and debts of $	as follows: Motor Vehicle $	Home $	Other Real
Property $	Child Support paid direct $	Credit Cards $	Medical Bills $	Cost of
medicines (monthly) $
Other$
I have a private lawyer in this case	Yes No

A person who knowingly provides false information to the clerk or the court in seeking a determination of indigent status under s. 57.082, F.S. commits a misdemeanor of the first degree punishable as provided in s775.082, 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 on	, 20
Signature of Applicant for Indigent Status
Date of Birth	Driver’s License or ID Number	Print Full Legal Name
Phone Number:
Address: Street, City, State, Zip Code
This form was completed with the assistance of:
Clerk/Deputy Clerk/Other authorized person

CLERK’S DETERMINATION

Based on the information in this Application, I have determined the applicant to be ( ) Indigent ( ) Not Indigent, according to s. 57.082, FS.

Dated on	, 20
Clerk of the Circuit Court
By	, Deputy Clerk

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

How-To Guide	TextBookDiscrimination.com/Guides/Indigence/State_ACI
Samples	TextBookDiscrimination.com/Files/Indigence
Templates	TextBookDiscrimination.com/Templates/

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