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.

Extracted Text for Proper Search

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