Fla. R. Crim. P. 3.984

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As amended through March 26, 2024

Rule 3.984 - APPLICATION FOR CRIMINAL INDIGENT STATUS

IN THE CIRCUIT/COUNTY COURT OF THE ____________________ JUDICIAL CIRCUIT IN AND FOR _________________ COUNTY, FLORIDA

STATE OF FLORIDA vs.

CASE NO.________________

_________________

Defendant/Minor Child

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 support payments)

3. I have other income paid ( ) weekly ( ) bi-weekly ( ) semimonthly ( ) monthly ( ) yearly: (Circle "Yes" and fill in the amount if you have this kind of income, otherwise circle "No.")

Social Security benefits....................	Yes	$____________	No
Unemployment compensation..........	Yes	$____________	No
Union Funds...................................	. Yes	$____________	No
Workers compensation....................	. Yes	$____________	No
Retirement/pensions.......................	Yes	$____________	No
Trusts or gifts..................................	Yes	$____________	No
Veterans' benefit..............................	Yes	$____________	No
Child support or other regular support
from family members/spouse..........	Yes	$____________	No
Rental income..................................	Yes	$____________	No
Dividends or interest.......................	Yes	$____________	No
Other kinds of income not on the list	Yes	$___________	_ No

4. I have other assets: (Circle "Yes" and fill in the value of the property, otherwise circle "No")

Cash...............................................	. Yes	$____________	No
Bank account(s)..............................	. Yes	$____________	No
Certificates of deposit or money market accounts.............................	Yes	$____________	No
* Equity in Motor vehicles/Boats/ Other tangible property...................	Yes	$____________	No
Savings...........................................	. Yes	$____________	No
Stocks/bonds..................................	Yes	$____________	No
* Equity in Real estate (excluding homestead).....................	. Yes	$____________	No
* include expectancy of an interest i	n such property

5. I have a total amount of liabilities and debts in the amount of $ .

6. I receive: (Circle "Yes" or "No")

Temporary Assistance for Needy Families-Cash

Assistance...............................................................

Yes

Poverty-related veterans'

benefits...................................................................

Yes

Supplemental Security Income

(SSI)........................................................................

. Yes

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 in seeking a determination of indigent status under section 27.52, Florida Statutes, commits a misdemeanor of the first degree, punishable as provided in section 775.082, Florida Statutes, or section 775.083, Florida Statutes. I attest that the information I have provided on this Application is true and accurate.

Signed this_________ day of______________, 20.
Date of Birth_____________Status	__________________________ Signature of Applicant for Indigent
Last 4 Digits of Driver's License or ID Number_________	Print full legal name________________
Address________________
City, State, Zip________________
Phone number________________

Signed this_________ day of______________, 20.

Date of Birth_____________Status

__________________________

Signature of Applicant for Indigent

Last 4 Digits of Driver's License or ID Number_________

Print full legal name________________

Address________________

City, State, Zip________________

Phone number________________

CLERK'S DETERMINATION

__________Based on the information in this Application, I have determined the applicant to be ( ) Indigent ( ) Not 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

__________________________

This form was completed with the assistance of authorized person

__________________________

Clerk/Deputy Clerk/Other

APPLICANTS FOUND NOT INDIGENT MAY SEEK REVIEW BY ASKING FOR A HEARING TIME. Sign here if you want the judge to review the clerk's decision of not indigent._____________________

FL. R. Crim. P. 3.984

Amended by 188 So.3d 764, 185 So.3d 1169, effective 1/1/2016; amended by 5 So.3d 662, effective 3/19/2009; amended by 910 So.2d 194, effective 7/1/2005; adopted by 900 So.2d 528, effective 4/7/2005.