Application For Determination Of Civil Indigent Status - Lee County, Florida - 2009
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2IN THE ___________ COURT OF THE TWENTIETH JUDICIAL CIRCUIT IN AND FOR
LEE COUNTY, FLORIDA
CIVIL ACTION
_____________________________________
Plaintiff/Petitioner or In the Interest Of
vs.
Case No.________________________
______________________________________
Defendant//Respondent
APPLICATION FOR DETERMINATION OF CIVIL INDIGENT STATUS
Notice to Applicant: If you do not qualify for civil indigence you may 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
Homestead Real Property*......................... Yes $__________No
Certificates of deposit or
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 $ __________.
F.S. 57.081
Rev. 7-09
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