Rule 3.984. 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)

  1. 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

  1. 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

  1. I have a total amount of liabilities and debts in the amount of
    $                     .
  2. 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

  1. 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.