Application For Determination Of Civil Indigent Status - Martin County, Florida
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2IN THE CIRCUIT/COUNTY COURT OF THE ------------------ JUDICIAL CIRCUIT
NINETEENTH
IN AND FOR ---------------- COUNTY, FLORIDA
MARTIN
_____________________________________
CASE NO.______________________
Plaintiff/Petitioner or In the Interest Of
vs.
______________________________________
Defendant//Respondent
APPLICATION FOR DETERMINATION OF CIVIL INDIGENT STATUS
Notice to Applicant: If you qualify for civil indigence you must enroll in the clerk’s office payment plan and pay a
one-time administrative fee of $25.00. This fee shall not be charged for Dependency or Chapter 39 Termination of
Parental Rights actions.
1. I have ______dependents. (Include only those persons you list on your U.S. Income tax return.)
Are you Married?...Yes….No Does your Spouse Work?...Yes….No
Annual Spouse Income? $_____________
2. I have a net income of $_______________ paid ( ) weekly ( ) every two weeks ( ) semi-monthly ( ) monthly ( ) yearly ( ) other
_____________.
(Net income is your total income including salary, wages, bonuses, commissions, allowances, overtime, tips and similar payments,
minus deductions required by law and other court-ordered payments such as child support.)
3. I have other income paid ( ) weekly ( ) every two weeks ( ) semi-monthly ( ) monthly ( ) yearly ( ) other _____________.
(Circle “Yes” and fill in the amount if you have this kind of income, otherwise circle “No”)
Second Job .............................................Yes $ __________ No
Veterans’ benefits....................................................Yes $ __________
No
Social Security benefits
Workers compensation............................................Yes $ __________
No
For you....................................Yes $ __________ No
Income from absent family members ......................Yes $ __________
No
For child(ren) ..........................Yes $ __________ No
Stocks/bonds ...........................................................Yes $ __________
No
Unemployment compensation ................Yes $ __________ No
Rental income..........................................................Yes $ __________
No
Union payments ......................................Yes $ __________ No
Dividends or interest................................................Yes $ __________
No
Retirement/pensions ...............................Yes $ __________ No
Other kinds of income not on the list .......................Yes $ __________
No
Trusts ......................................................Yes $ __________ No
Gifts .........................................................................Yes $ __________
No
I understand that I will be required to make payments for fees and costs to the clerk in accordance with §57.082(5), Florida Statutes,
as provided by law, although I may agree to pay more if I choose to do so.
4. I have other assets: (Circle “yes” and fill in the value of the property, otherwise circle “No”)
Cash........................................................Yes $ __________ No
Savings account ......................................................Yes $ __________
No
Bank account(s) ......................................Yes $ __________ No
Stocks/bonds ...........................................................Yes $ __________
No
Certificates of deposit or
Homestead Real Property*......................................Yes $ __________
No
money market accounts..........................Yes $ __________ No
Motor Vehicle* .........................................................Yes $ __________
No
Boats* .....................................................Yes $ __________ No
Non-homestead real property/real estate* ..............Yes $ __________
No
*show loans on these assets in paragraph 5
Check one: I ( ) DO ( ) DO NOT expect to receive more assets in the near future. The asset is_____________________________.
5.
I have total liabilities and debts of $________
as follows:
Motor Vehicle $__________, Home $__________, Other Real
Property $__________, Child Support paid direct
$__________, Credit Cards $__________, Medical Bills $__________, Cost of
medicines (monthly) $______________,
Other $__________.
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 s. 57.082, 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
Driver’s License or ID Number
Print Full Legal Name _____________________
Phone Number: __________________________
_______________________________________
Address, P O Address, Street, City, State, Zip Code
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