IN THE CIRCUIT/COUNTY COURT OF THE SIXTH JUDICIAL CIRCUIT
IN AND FOR PINELLAS COUNTY, FLORIDA
_______________________ ______________ 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
CLERK’S DETERMINATION
Based on the information in this Application, I have determined the applicant to be ( ) Indigent ( ) Not Indigent, according to s. 57.082, F.S.
Dated this _________ day of ______________, 20 ____. Clerk of the Circuit Court by
This form was completed with the assistance of: ____________________________________
Clerk/Deputy Clerk/Other authorized person.
APPLICANTS FOUND NOT TO BE INDIGENT MAY SEEK REVIEW BY A JUDGE BY ASKING FOR A HEARING TIME.
THERE IS NO FEE FOR THIS REVIEW.
Sign here if you want the judge to review the clerk’s decision __________________________________________
APIS (if approved) (APID) (if denied)
COCR/COCIV/SC/P 001 (Revised – 10/2007)
