ORIGINAL APPLICATION FOR INDIGENT STATUS PUBLIC DEFENDER APPOINTED

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                          IN THE CIRCUIT/COUNTY COURT OF THE JUDICIAL CIRCUT
IN AND FOR. COUNTY, FLORIDA ~ -
ATE CASE NO. DO & 324
DefendantMi
APPLICATION FOR CRIMINAL INDIGENT STATUS
MC. scene THE APPONTMENT OF THE PUBLIC DEFENDER OR
—— | HAVE A PRIVATE ATTORNEY OR AM SELF-REPRESENTED AND SEEK DETERMINATION OF INDIGENCE STATUS FOR COSTS

‘Notice to Applicant: The provision of a public defendericourt 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 behaif 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 thi…