Application For Criminal Indigent Status Form - Pasco County, Florida

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IN THE CIRCUIT/COUNTY COURT OF THE SIXTH JUDICIAL CIRCUIT

IN AND FOR PASCO 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

____ 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 from

Union funds .................................................. Yes $_________________ No

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”)

Cash

.................................................... Yes $_________________ No

Savings .........................................................Yes $_________________ No

Bank account(s)............................................ Yes $_________________ No

Stocks/bonds ................................................Yes $_________________ No

Certificates of deposit or

*Equity in homestead real estate .................Yes $_________________ No

money market accounts ......................... Yes $_________________ No

*Equity in non-homestead real estate ..........Yes $_________________ No

*Equity in motor vehicles .............................. Yes $_________________ No

*include expectancy of an interest in such property

*Equity in boats/other tangible property ....... Yes $_________________ No

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

Supplemental Security Income (SSI) ............................................... Yes

Poverty- related veterans’ benefits ............................................Yes

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.

______________

Signed on

Signature of applicant for indigent status

Print full legal name:

Date of Birth

Address:

City, State, Zip:

Last four digits of Driver’s License or ID Number

Phone number:

E-mail

Address:

CLERK DETERMINATION