IN THE CIRCUIT/COUNTY COURT OF THE SEVENTH JUDICIAL CIRCUIT

IN AND FOR VOLUSIA COUNTY, FLORIDA

CASE NO.

DIVISION

,

Plaintiff/Petitioner or In the Interest of

vs.

.

Defendant/Respondent

APPLICATION FOR DETERMINATION OF CIVIL INDIGENT STATUS

Notice to Applicant: If you do not qualify for civil indigence and you cannot afford to pay the filing fee, you must enroll in the Clerk’s Office payment plan and pay a one-time administrative fee of $25.00.

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 $_________in 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	Veteran’s benefits	Yes $______________No

Unemployment compensation	Yes $__________ No	Child Support or other regular support

Union funds	Yes $__________ No	from family members/spouse	Yes $______________ No

Worker’s compensation	Yes $__________ No	Rental income	Yes $______________ No

Retirement/pensions	Yes $__________ No	Dividends or interests	Yes $______________ No

Trusts or gifts	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	Savings	Yes $______________ No

Bank account(s)	Yes $__________ No	Stocks and bonds	Yes $______________ No

Certificates of deposit or	*Equity in real estate (excluding

money market account	Yes $__________ No	homestead)	Yes $______________ No

*Equity in Boats and other tangible	*Equity in motor vehicles	Yes $ _____________ No

property	Yes $__________ No

5. I have total amount of liabilities and debts in the amount of $_______________________.

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 F.S. 57.082 commits a misdemeanor of the first degree, punishable as provided in s.775.082 or s.775.083. 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	Print Full Legal Name__________________________________________

_________________________________

Last four digits or Driver License or ID #	Address, P O Address, Street, City, State, Zip Code

Note: If applicant is determined by the clerk to be Not Indigent, you may seek judicial review by filing a petition to review.

CLERK’S DETERMINATION

Based on the information in this Application, I have determined the applicant to be_______ Indigent _______ Not indigent, according to

57.082, F.S.

Dated this _______ day of ________________, 20___.

This form was completed with the assistance of _______________________ Clerk/Deputy Clerk/Other.

Deputy Clerk