IN THE CIRCUIT/COUNTY COURT OF THE ___________________ JUDICIAL CIRCUIT
IN AND FOR ____________________ 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 fees are waived; other costs and fees are not waived.
1. I have ______dependents. (Include only those persons you list on your U.S. Income tax return.)
Are you Married?...Yes….No Does your Spouse Work?...Yes….No Annual Spouse Income? $_____________
2. 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.)
3. 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 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.
4. 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 Homestead Real Property* ............................. Yes $ No
Money market accounts................... Yes $ No Motor Vehicle*................................................. Yes $ No
Boats* .......................................... Yes $
No Non-homestead real property/real estate* ...... Yes $ No
Other assets* Yes $ No
Check one: I ( ) DO ( ) DO NOT expect to receive more assets in the near future. The asset
is_____________________________.
5. I have total liabilities and debts of $________ as follows: Motor Vehicle $__________, Home $__________, Boat
$__________, Non-homestead Real Property $__________, Child Support paid direct $__________, Credit Cards
$__________, Medical Bills $__________, Cost of medicines (monthly) $______________, Other $__________.
6. 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 s.775.082, 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
Year of Birth Last 4 digits of Driver License or ID Number Print Full Legal Name
Email address: Phone Number/s:
_____________________________________________________________________________________________________________
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,
F.S.
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 ______________________________________________________________
Updated 5/1/2019
