Affidavit for Criminal Indigent Status
If an affiant in a case wants to have a public defender appointed, he/she has to execute this affidavit.
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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 Veterans’ benefit……………………….... Yes $_________________ No Unemployment compensation…………….. Yes $_________________ No Child support or other regular support Union Funds…………………………………. Yes $_________________ No from family members/spouse……… Yes $_________________ No Workers compensation…………………….. Yes $_________________ No Rental income…………………………… Yes $_________________ No Retirement/pensions………………..……… Yes $_________________ No Dividends or interest…………………….. 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.” Use the back of this form to provide additional information.) Cash…………………………………………. Yes $_________________ No Savings………………………………………… Yes $_________________ No Bank account(s)…………………………….. Yes $_________________ No Stocks/bonds………………………………….. Yes $_________________ No Certificates of deposit or *Equity in Real estate (excluding homestead) Yes $_________________ No money market accounts…………….. Yes $_________________ No *Equity means value minus loans. Also list *Equity in Motor Vehicles/Boats/ any expectancy in an interest in such property. Other tangible property……………… Yes $_________________ No List the address of this property: List the year/make/model and tag #: ________________________________ Address _________________________________________ City, State, Zip _________________________________________ County of Residence _________________________________________ 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 s. 27.52, 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 this _________ day of _______________, 20____. Signature of Applicant for Indigent Status Date of Birth ________________________________ Print Full Legal Name ____________________________________ Address __________________________________ Driver’s license or ID number _________________ 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 with the assistance of _____________________________________ Clerk/Deputy Clerk/Other 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. _____________________________________________________ 06/18/10
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