APPLICATION FOR CRIMINAL INDIGENT STATUS IN THE CIRCUIT/COUNTY COURT OF THE ____________________ JUDICIAL CIRCUIT IN AND FOR _________________ 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: (Circle “Yes” and fill in the amount if you have this kind of income, otherwise circle “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: (Circle “Yes” and fill in the value of the property, otherwise circle “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: (Circle “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 . Clerk of the Circuit Court This form was completed Clerk/Deputy Clerk/Other with the assistance of 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.