LUN LOE UINUULL UR UVUUNLY CUUKRL UF LHE 4 JUVDIULAL UIRUULIL UN
`
`STATE OF FLORIDA Ys.
`WV Widens,
`(aninng
`
`Defendant/Minor Child
`
`AND FOR DUVAL COUNTY, FLORIDA
`
`CASE NO, 23
`
`- Flo
`
`.
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`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 DETERMINATIONOF 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 judgmentand lien may
`be imposed againstall 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 makingthis
`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 notliving at home and do not include a working spouse or yourself.)
`) yearly.
`(
`2. Lhave a take home income of $ ____ paid (_) weekly
`(
`) bi-weekly } semi-monthly
`(
`) monthly
`(Take home income equals salary, wages, bonuses, commissions, allowances, overtime, tips and simi
`jar payments, minus deductions required by law and other
`court ordered support payments.
`"3. I have other income paid (_
`) weekly (_
`) bi-weekly (
`you have this kind ofincome, otherwisecircle ‘‘No’’)
`Yes$__Ss Ss«Noo
`Veterans’ benefit...............
`(No
`Social Security benefits ......
`Yes$__.__—————s—s
`;
`Child support or other regular support
`Unemployment compensation..
`Yes$__.-Ss No
`from family members/spouse.... . Yes$__....—s—~‘No
`Union Funds.............. Yes$__._———s— ‘No
`Rental income............0005.
`Yes$__—————C(NNo
`Workers compensation....... Yes$__—————sCNNoo
`
`Retirement/pensions......... Yes$__._ss‘(No Dividendsor interest ....... “ee Yes$__——s«(No
`Trusts or gifts............. Yes$_...._-—~No
`Other kinds of income not on the list.
`Yes$____—~—~—s—~‘No
`Ihaveother assets: (Circle ‘“‘Yes’’ andfill in the valueofthe property, otherwisecircle ‘‘No.”’ Use the backofthisform to provide additionalinformation.)
`Cash... eee eee eee Yes$__.————s—*‘No
`SAVINGS. eee ee Yes $
`No
`
`Bank account(s) ........... Yes$__ CSN Stocksfbonds.. 1... eee eee eee Yes$___ss'No
`Certificates of deposit or.
`*Equity in Real Estate (excluding homestead). Yes$__.~~~~—~—s~‘No
`money market accounts..... Yes$__—CUN '
`*Equity means value minus loans. Also list
`*Equity in Motor Vehicles/Boats/
`any expectancy in an interest in such property.
`Yes$___Ss No
`ther tangible property... ..
`List the address of this property:
`List the year/make/model and tag #:____— Address
`;
`City, State, Zip
`County of Residence
`5. I have a total. amountofliabilities and debts in the amount of$__-= CSC
`6. I receive: (Circle ‘Yes’’ or ‘‘No’’)
`.
`No
`Temporary Assistance for Needy Families-Cash Assistance ....... Yes
`No
`Poverty-related veterans’ benefits... ....... 0. ccc cece eee ees Yes
`No
`Supplemental Security Income (SSI).......... 0.00. c ee eae Yes
`_.
`DUVAL CLERK OF COURT
`
`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 inseeking a determination of indigent status under s. 27.52, FS.,
`commits a misdemeanorof 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 __.._——s dayof si 20 :
`:
`Signature of Applicant for Indigent Status
`Print Full Legal Name
`Address
`City, State, Zip
`Phone Number
`
`4,
`
`Date of Birth
`
`Driver’s license or ID number
`
`) semi-monthly (
`
`) monthly (_) yearly: (Circle ‘‘Yes’’ andfill in the amountif
`
`- FE I L E D
`.
`
`_ APR 14 2023
`,
`
`
`
`
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`CLERK’S DETERMINATION
`Based on the information in this Application, I have determined the applicant to be (_) Indigent
`The Public Defender is hereby appointed to the case listed above until relieved by the Court.
`Dated this_______ day of_________, 20__.
`
`Clerk of the Circuit Court
`
`(
`
` ) Not Indigent
`
`This form was completed with the assistance of
`
`Clerk/Deputy Clerk/Other authorized person
`APPLICANTS FOUND NOT INDIGENT MAY SEEK REVIEW BY ASKING FOR A HEARINGTIME.Sign here if you want’
`the judge to review the clerk’s decision of not indigent
`O7/11
`MTT AAMT oo ONT RT fam ony TA Remar Ar meee Ae See Re re Le
`we sana
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