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)

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.