Developed by the Florida Clerks of Court Operations Corporation
IN THE CIRCUIT/COUNTY COURT OF THE ____________________ JUDICIAL CIRCUIT
IN AND FOR _________________ COUNTY, FLORIDA
STATE OF FLORIDA vs.
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
3. I have other income paid ( ) weekly ( ) bi-weekly ( ) semi-monthly ( ) monthly ( ) yearly: (Circle “Yes” and fill in the amount if you have this