Approval of Form for Use by Clerks of the Circuit Courts - Rules Regulating the Florida Bar

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Supreme Court of Florida ____________ No. SC04-994 ____________ IN RE: APPROVAL OF FORM FOR USE BY CLERKS OF THE CIRCUIT COURTS PURSUANT TO RULE 10-2.1(a) OF THE RULES REGULATING THE FLORIDA BAR. [June 17, 2004] CORRECTED OPINION PER CURIAM. In 2004, the Legislature amended section 27.52, Florida Statutes, Determination of Indigence, to provide that the circuit court clerks shall use "a form developed by the Supreme Court" to determine indigency for purposes of appointing the public defender or a private attorney or "any other due process services." See Ch. 2004-265, § 9, at 14, Laws of Fla.1 Section 27.52 was also amended to require the clerk of court to assist a person who appears before the clerk and requests assistance in completing the form. See id. Chapter 2004-265, Laws of Florida, has an effective date of July 1, 2004. See id. § 109, at 81. 1. We have jurisdiction. See art. V, § 2(a), Fla Const. In order to implement this legislation, the Court on its own motion hereby approves and authorizes the publication of an affidavit of indigent status form for use by the clerks of the circuit courts. The Court approves this form pursuant to rule 10-2.1(a) of the Rules Regulating the Florida Bar, which allows nonlawyers to assist in the completion of legal forms approved by this Court. However, only the clerks of the circuit courts are authorized to assist individuals in completion of this form. Rule 10-2.1(a) requires the individual who assisted in preparation of the form to provide a disclosure to the individual who sought assistance. The Court directs the circuit court clerks to this rule for language to be included in the disclosure. Because local procedures may vary from circuit to circuit, the chief judge of each circuit is authorized to prepare instructions for the use of the approved form. Instructions shall be filed with the clerk of court in the respective circuit and with the clerk of this Court. The form as approved and authorized for publication is set forth in the appendix to this opinion, effective July 1, 2004. By approval of this form, the Court expresses no opinion as to its correctness or applicability, or on the substance of the new legislation. This opinion and the form discussed herein may -2- be accessed and downloaded from this Court's website at www.flcourts.org. It is so ordered. ANSTEAD, C.J., and WELLS, PARIENTE, LEWIS, QUINCE, CANTERO, and BELL, JJ., concur. NO MOTION FOR REHEARING WILL BE ALLOWED. Original Proceeding - Rules Regulating The Florida Bar -3- IN THE CIRCUIT/COUNTY COURT OF THE __________JUDICIAL CIRCUIT IN AND FOR __________________COUNTY, FLORIDA STATE OF FLORIDA vs. / IN THE INTEREST OF: CASE NO.______________________________________ ___________________________________ Defendant / Minor Child(ren) / Respondent AFFIDAVIT OF INDIGENT STATUS Notice to Applicant: The provision of a public defender/court-appointed lawyer is 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). If the $40.00 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 child or tax-dependent adult, the information contained in this affidavit must include your income and assets. 1. I have ______dependents. (Do not include children not living at home and do not include working spouses.) 2. I have take-home income of $________________ 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 payments.) 3. I have $_____________ in other annual income: (Circle Yes and fill in the amount if you have this kind of income or circle No if you do not have this kind of income) 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 benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes $_________ No 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 $_______________ in other assets. (Circle Yes and fill in the value of the property or circle No if you do not have this kind of property.) Cash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes $_________ No Savings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes $_________ No Bank account(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes $_________ No Stocks and bonds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes $_________ No Certificates of deposit or money market accounts . . . . . . . . . . . . . . . . . . . . . . . . Yes $_________ No Real estate (your ownership interest) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes $_________ No Boat(s) or aircraft (your ownership interest) . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes $_________ No Motor vehicle(s) (your ownership interest) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes $_________ No Life Insurance (cash value) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes $_________ No Other valuable tangible property (like jewelry, coin collections, etc.) . . . . . . . . Yes $_________ No 5. I receive: (Circle Yes or No ) Temp. Assistance for Needy Families-Cash Assistance . . . . . . . . . . . . . . . . . . . Yes Poverty-related veterans benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes Supplemental Security Income (SSI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No No No 6. I have been released on bail in the amount of $5,000 or more in this case . . . . . . Yes No 7. I have a private lawyer in this case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No Florida Supreme Court Approved Affidavit of Indigent Status (7/04) 8. I expect to get or receive something of value at a later date (Like a tax refund, payments from lawsuits, accrued vacation leave, a bonus, or inheritance) . . . . . . . . . Yes $_________ No **(Elect and complete either the notarized oath or the written declaration below pursuant to section 92.525, Florida Statutes) NOTARIZED OATH I, _________________________ (full legal name), being first duly sworn, state under oath and under penalty of perjury that the facts stated in the foregoing affidavit are true. Signature of Applicant for Indigent Status Date Signed PRINT Full Legal Name ________________________________________ Address _____________________________________________________ Driver s License # or ID # ______________________________________ Date of Birth ________________________________________________ Telephone WRITTEN DECLARATION Under penalties of perjury, I declare that the facts stated in the foregoing affidavit are true. _____________________________________________________ Signature of Applicant for Indigent Status Date Signed PRINT Full Legal Name __________________________________ Address ________________________________________________ Driver s License # or ID # _________________________________ Date of Birth ___________________________________________ Telephone **(If a clerk or deputy clerk helped you fill out this form, he or she must fill out the blank below.) This form was completed with the assistance of , Clerk/Deputy Clerk. DETERMINATION OF INDIGENT STATUS Based on the information in this Affidavit, I have determined that the applicant is ( ) Indigent ( ) Not Indigent pursuant to section 27.52, F.S. _________________________________________ ,Clerk of Court by Deputy Clerk Florida Supreme Court Approved Affidavit of Indigent Status (7/04) ________________________20__ Date

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