Application for Indigent Status (2)BEFORE THE SPECIAL MASTER OF THE
CITY OF MIAMI BEACH, FLORIDA
Appellant/Violator
vs.
City of Miami Beach
CASE NO.
APPLICATION FOR DETERMINATION OF CIVIL INDIGENT STATUS
1. 1 have dependents. (Include only those persons you list on your U.S. Income tax return.)
Are you Married? ... Yes .... No Does your Spouse Work? ... Yes....No Annual Spouse Income? $
2.1 have a net income of $ paid () weekly () every two weeks () semi - monthly () monthly
( ) yearly ( ) other
(Net income is your total income including salary, wages, bonuses, commissions, allowances, overtime, tips and similar payments, minus
deductions required by law and other court- ordered payments such as child support.)
3.1 have other income paid () weekly () every two weeks () semi - monthly () monthly () yearly () other
(Circle "Yes" and fill in the amount if you have this kind of income, otherwise circle "No')
Second Job ................. ............................Yes
$
No
Veterans' benefits ....................................................
Yes $
No
Social Security benefits
$
No
Workers compensation ................ ............................Yes
$
No
For you ..................... ............................Yes
$
No
Income from absent family members ......................Yes
$
No
For child(ren) ............. ............................Yes
$
No
Stocks/bonds ...........................................................
Yes $
No
Unemployment compensation ................Yes
$
No
Rental income ..........................................................
Yes $
No
Union payments .......... ............................Yes
$
No
Dividends or interest ................................................
Yes $
No
Retirement / pensions ... ............................Yes
$
No
Other kinds of income not on the list .......................
Yes $
No
Trusts.......................... ............................Yes
$
No
Gifts .........................................................................
Yes $
No
4. 1 have other assets: (Circle "yes" and fill in the value of the property, otherwise circle "No')
Cash ............................ ............................Yes
$
No
Savings account .......................... ............................Yes
$
No
Bank account(s) .......... ............................Yes
$
No
Stocks/bonds ...........................................................
Yes $
No
Certificates of deposit or
Homestead Real Property' .......... ............................Yes
$
No
Money market accounts .....................
Yes $
No
Motor Vehicle* .........................................................
Yes $
No
Boats' ......................... ............................Yes
$
No
Non - homestead real property /real estate' ..............Yes
$
No
'show loans on these assets in paragraph 5
Check one: I () DO () DO NOT expect to receive more assets in the near future. The asset is
5. 1 have total liabilities and debts of $ as follows: Motor Vehicle $ , Home $
Other Real Property $ Child Support paid direct $ Credit Cards $_
Medical Bills $ , Cost of medicines (monthly) $ _, Other $
6.1 have a private lawyer in this case Yes No
A person who knowingly provides false information to the clerk or the court in seeking a determination of indigent status
under s. 57.082, F.S. commits a misdemeanor of 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 day of
1 20
Date of Birth Driver's License or ID Number
Signature of Applicant for Indigent Status
Print Full Legal Name
Phone Number:
Address or P.O. Box Address, Street,
City, State, Zip Code
CLERK'S DETERMINATION
Based on the information on this Application, I have determined the applicant to be ( ) Indigent ( ) Not Indigent
Dated this day of , 20
Clerk of the Special Master
This form was completed with the assistance of
Clerk/Deputy Clerk /other authorized person
APPLICANTS FOUND NOT TO BE INDIGENT MAY SEEK REVIEW BY THE SPECIAL MASTER BY ASKING FOR A
HEARING TIME. THERE IS NO FEE FOR THIS REVIEW.
Sign here if you want the Special Master to review the Clerk's decision:
F:AattoATURN \MISCELLN \Form -Application for Determination of Civil Indigent Status 2- 2011.docx