In order to be considered for criminal indigent status, you must complete and submit an application form. The form can be found on the website of your state's legal services organization. Completing and submitting the application is the first step in getting the help you need. The staff at your state's legal services organization will review your application and let you know if you are eligible for criminal indigent status. If you are not sure where to find your state's legal services organization, or if you have any other questions about completing the application, please call our office toll free at 1-800-868-7529. We would be happy to help you!
| Question | Answer |
|---|---|
| Form Name | Application For Criminal Indigent Status Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | florida criminal indigent form, florida application criminal indigent status, application for criminal indigent status fl, criminal indigent status form |
IN THE CIRCUIT/COUNTY COURT OF THE ____________________ JUDICIAL CIRCUIT
IN AND FOR |
_________________ COUNTY, FLORIDA |
STATE OF FLORIDA vs. |
CASE NO.______________________________________ |
______________________________________ |
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Defendant/Minor Child |
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APPLICATION FOR CRIMINAL INDIGENT STATUS
____ I AM SEEKING THE APPOINTMENT OF THE PUBLIC DEFENDER
OR
____ I HAVE A PRIVATE ATTORNEY OR AM
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
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 ( )
(Take home income equals salary, wages, bonuses, commissions, allowances, overtime, tips and similar payments, MINUS deductions required by law and other
3.I have other income paid ( ) weekly ( )
Social Security benefits…………………….. Yes $_________________ |
No |
Veterans’ benefit……………………….... Yes $_________________ |
No |
Unemployment compensation…………….. Yes $_________________ |
No |
Child support or other regular support |
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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 |
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Bank account(s)…………………………….. Yes $_________________ |
No |
Stocks/bonds………………………………….. Yes $_________________ |
No |
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Certificates of deposit or |
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*Equity in Real estate (excluding homestead) Yes $_________________ |
No |
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money market accounts…………….. Yes $_________________ |
No |
*Equity means value minus loans. Also list |
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*Equity in Motor Vehicles/Boats/ |
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any expectancy in an interest in such property. |
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Other tangible property……………… Yes $_________________ |
No |
List the address of this property: |
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List the year/make/model and tag #: ________________________________ |
Address |
_________________________________________ |
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City, State, Zip |
_________________________________________ |
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County of Residence _________________________________________ |
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5. |
I have a total amount of liabilities and debts in the amount of $___________________, |
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6. |
I receive: (Circle “Yes” or “No”) |
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Temporary Assistance for Needy |
Yes |
No |
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Yes |
No |
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Supplemental Security Income (SSI)………………………………………………………………………………………………………………………….…. |
Yes |
No |
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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____. |
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Signature of Applicant for Indigent Status |
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Date of Birth ________________________________ |
Print Full Legal Name |
____________________________________ |
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Address |
__________________________________ |
Driver’s license or ID number _________________ |
City, State, Zip |
__________________________________ |
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Phone number |
__________________________________ |
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CLERK’S DETERMINATION |
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_Based on the information in this Application, I have determined the applicant to be ( |
) Indigent ( ) Not Indigent |
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______ |
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_______ |
The Public Defender is hereby appointed to the case listed above until relieved by the Court. |
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Dated this _________ day of ______________, 20 ____. |
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_____________________________________ |
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Clerk of the Circuit Court |
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This form was completed with the assistance of |
_____________________________________ |
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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