Defendant/Minor Child
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`.
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`AND FOR DUVAL COUNTY, FLORIDA
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`_
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`CASE NO. 20-1392
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`APPLICATION FOR CRIMINAL INDIGENT STATUS
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`___1 AM SEEKING THE{APPOINTMENT OF THE PUBLIC DEFENDER
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`___.. 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
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`within7days, 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
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`affidavit on behalf of a minor or tax-dependent adult, the information contained in this application must include your incomeand assets.
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`1. I have
`dependents. (Do notinclude children not living at home and do not include a working spouse or yourself.)
`
`) yearly.
`(
`2.
`| have a take home incomeof $
`paid (_) weekly
`(_
`) bi-weekly
`(
`} semi-monthly
`(
`) monthly
`(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.
`I have other income
`paid (_
`
`) weekly (_
`
`) bi-weekly (_) semi-monthly (_) monthly (_
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`) yearly: (Circle ‘‘Yes’’ and fill in the amount if
`
`3.
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`you have this kind ofincome, otherwise circle ‘‘No’’)
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`Yes$__.._+__+__._-~‘No
`
`Veterans’ benefit..............,
`Social Security benefits ...... Yes$__ CNN
`Child support or other regular support
`Unemployment compensation...
`Yes$__.~~ No
`. Yes$__._.__—s—~/No
`from family members/spouse .
`.
`.
`.
`Union Funds.............. Yes$______s'No
`Rental income................. Yes$_ NO
`Workers compensation....... Yes$____———s“‘No
`Retirement/pensions.........
`Yes$__SCN Dividends or interest... .......... Yes$__._....._s ‘No
`Trusts or gifts... 00... 0.04. Yes$___._s-s«“No
`Other kinds of incomenot on the list. Yes$_________ No
`4, Thave otherassets: (Circle ‘‘Yes’’ andfill in the value ofthe property, otherwisecircle ‘‘No.’’ Use the back ofthisform to provide additional information.)
`Cash... eee eee eee Yes$__ CN
`SaVINGS. eee Yes$_ CN
`Bank account(s) ...........
`Yes$__Ss tsé«CNNo
`Stocks/bonds..... eee ee eee Yes$__ SiC t:*C«“ND
`Certificates of deposit or
`“Equity in Real Estate (excluding homestead). Yes$......#+=+-+_=_—=—»s-'No
`money market accounts. .... Yes$___..._—*‘No
`Equity means value minus loans. Alsolist
`“Equity in Motor Vehicles/Boats/
`any expectancy in an interest in such property.
`ther tangible property... .. Yes$__s SN
`List the address of this property:
`List the year/make/model and tag #:_--_>_>_>EE
`Address
`City, State, Zip
`County of Residence
`
`
`
`F T
`I have a total amountof liabilities and debts in the amountof $
`. L E D
`I receive: (Circle “‘Yes’’ or “‘No’’)
`
`
`4
`No
`Temporary Assistance for Needy Families-Cash Assistance ....... Yes
`JUN 2 4 2029
`No
`Poverty-related veterans’ benefits... 02.0... cece eee ee Yes
`
`Supplemental Security Income (SSI)... 6.0... ee ee Yes
`No
`Posted by:|SelfDONpmebl
`I have been released on bail in the amount of $
`Cash
`Surety
`7.
`
`
`FS
`indigent status tnders~-2
`A person who knowingly provides false information to the clerk or the court in seeking a determination of
`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.
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`
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`Signed, this_______ dayof 20. LACBIEADSiNdUEetvOCOVEfS TO COUCENS
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`5.
`6.
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`Date of Birth
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`Driver’s license or ID number
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`Status
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`Signature of Applicantfor Indigefit
`Print Full Legal Name
`Address
`City, State, Zip
`Phone Number
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`CLERK’S DETERMINATION
`
`) Indigent
`_____ Based on the information in this Application, I have determined the applicant to be (
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`The Public Defender is hereby appointed to the case listed above until relieved by the Court.
`Dated this_.___ day of ___»__E, 200
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`Clerk of the Circuit Court
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`(
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` ) Not Indigent
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`This form was completed with the assistance of
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`Clerk/Deputy Clerk/Other authorized person
`APPLICANTS FOUND NOT INDIGENT MAY SEEK REVIEW BY ASKING FOR A HEARING TIME.Sign here if you want
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`the judge to review the clerk’s decision of not indigent.
`OT/tt
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`WHITE COPY - CLERK
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`PINK COPY - PUBLIC DEFENDER
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`GOLDENROD COPY - DEFENDANT
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`PS-1273
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`