
    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.
    No. SC04-994.
    Supreme Court of Florida.
    June 17, 2004.
   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 indigen-cy 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. 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.

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 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.

APPENDIX

IN THE CIRCUIT/COUNTY COURT OF THE_JUDICIAL CIRCUIT IN AND FOR_COUNTY, FLORIDA STATE OF FLORIDA WIN THE INTEREST OF: CASE NO_ Defendant / Minor Child(ren)/Respondent

AFFIDAVIT OF INDIGENT STATUS

Notice to Applicant: The provision of a public defender/courlnappointed 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 pareni/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 comt-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

Jf. I have $_in other assets. you do not have this kind of property.) (Circle “Yes” and fill in the value of the propeity or circle “No" if

Cash. . Yes $_ No

Savings. Yes $_ No

Bank accounts). 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 No

Poverty-related veterans’ benefits. Yes No

Supplemental Security Income (SSI). Yes 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

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 9Z.5&5, 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

**(ff 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.

_ _20_

,Clerk of Court by Deputy Clerk Date 
      
      . We have jurisdiction. See art. V, § 2(a), Fla Const.
     