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STATE OF FLORIDA

COMMISSION ON HUMAN RELATIONS

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 you must enroll in the clerk’s office payment plan and pay a one-time administrative fee of $25.00. This fee shall not be charged for Dependency or Chapter 39 Termination of Parental Rights actions.

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

*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 this	day of	, 20
Signature of Applicant for Indigent Status
Date of Birth	Driver’s License or ID Number	Print Full Legal Name
Phone Number:
Address, P O Address, Street, City, State, Zip Code

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 this	day of	, 20
Clerk of the Commission
This form was completed with the assistance of:
Clerk/Deputy Clerk/Other authorized person

APPLICANTS FOUND NOT TO BE INDIGENT MAY SEEK REVIEW BY THE CHAIR OF THE COMMISSION. THERE IS NO FEE FOR THIS REVIEW.
Sign here if you want the Chair of the Commission to review the clerk’s decision

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