On August 26, 2021 a
Party Statement
was filed
involving a dispute between
and
Baine, Casey Jo,
for Out of County
in the District Court of Charlotte County.
Preview
IN THE CIRCUIT / COURT OF THE 20th JUDICIAL CIRCUIT
IN AND FOR CHARLOTTE COUNTY, FLORIDA L- 4 24 O
STATE OF FLORIDA vs. BOOKING NUMBER: 202104718
BAINE, CASEY JO DATE OF BIRTH: 7/24/1985
Affidavit for Indigent Status losure Form
Pursuant to Rule 10-2.1 of the Rules Regulating the Florida Bar, before a nonlawyer assists a person in the completion of the
Affidavit of Indigent Status, the nonlawyer shall provide the person with a copy of this disclosure. A copy of the disclosure, signed by
both the nonlawyer and the person, shall be given to the person to retain and the nonlawyer shall keep a copy in the person's file.
The disclosure does not act as or constitute a waiver, disclaimer, or limitation of liability.
The Deputy Clerk/Pretrial Officer, whose signature appears below, will conduct a Pretrial interview and assist
me with the Affidavit of Indigent Status. The Deputy Clerk/Pretrial Officer has told me and J understand that
the Deputy Clerk/Pretrial Officer:
Is not a lawyer;
May not give legal advice or represent me in court;
Cannot tell me what my rights or remedies are or how to testify in court;
May only help me by asking me factual questions to fill in the blanks on the form;
May also tell me how to file the form;
May only help fill out a form that has been approved by the Supreme Court of Florida.
I can read English
1 I cannot read English but this disclosure form was read to me by in (language), which
J understand.
You have been found to be_X__ INDIGENT “_NOT INDIGENT. The $50.00 application fee is to be paid tot! the Clerk of Court
within 7 days or it will be added to any cost that may be assessed against you at the conclusion of your case. 169% ou have 68en found
indigent, the Public Defender will represent you. You must contact them at 350 E. Marion Avenue, Room 109953] Bunta Gouda, FLY FY
(941.637.2181) if released. If you are not released, they will contact you at the jail. If found not indigent you megstek ical eet
review by asking for a hearing time.
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“114230. 08/27/2021
Signature of. Applicant Date
/ Jennifer Cramer / 08/27/2021
Signature of Deputy Clerk/Pretrial Services Officer DateIN THE CIRCUIT / COURT OF THE 20th JUDICIAL CIRCUIT
IN AND FOR CHARLOTTE COUNTY, FLORIDA
, Y-324-o
STATE OF FLORIDA vs. BOOKING NUMBER: 202104718!
BAINE, CASEY JO DATE OF BIRTH: 7/24/1985
APPLICATION FOR CRIMINAL INDIGENT STATUS
1 AM SEEKING THE APPOINTMENT OF THE PUBLIC DEFENDER
OR
(_=sI 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 judgement 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 the 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.
I, Ihave Q dependants. (Do not include children not living at home and do not include a working spouse or yourself)
2. [have a take home income of $0.00 paid
(Take home income equals salary, wages, bonuses, commissions, allowances, overtime, tips and similiar payments, minus deductions required by law
and other court ordered support payments)
3. [have other income paid —_: (Circle "Yes” and fill in the amount if you have this kind of income, otherwise circle "No")
Social Security benefits Yes $0.00 NoX _ Veterans’ benefit Yes $0.00 NoX
Unemployment compensation YesX $900.00 No Child support or other regular support Yes $0.00 NoX
Union Funds Yes $0.00 NoX from family members / spouse
Workers compensation Yes $0.00 NoX Rental income Yes $0.00 NoX
Trusts or gifts Yes $0.00 NoX __ Dividends or interest Yes 0.00 NoX
Retirement / pensions ‘Yes $0.00 NoX — Other kinds of income not on the list Yes $0.00 NoX
4. [have other assets: (Circle "yes" and fill in the of the property, otherwise circle "No")
Cash Yes $0.00 NoX — Savings Yes 0.00 NoX
Bank account(s) Yes $0.00 NoX Stocks / bonds Yes $0.00 NoX
Certificate of deposit or money Yes. $0.00 NoX *Equity in homestead real estate Yes $0.00 NoX
market account(s) *Equity in non-homestead real estate
*Equity in Motor vehicle(s) Yes $0.00 NoX include expectency ofan interest in such Yes £0.00 Nox
*Equity in boats/ other tangible Yes $0.00 Nox Property
Property
5. Ihave a total amount of liabilities and debts in the amount of $0.00
6. L receive: (Circle "Yes" or "No")
Temporary Assistance for Need;y Families-Cash Assistance Yes $0.00 NoX
Poverty- related veterans’ benefits ‘Yes $0.00 NoX
Supplemental Security income (SSI) Yes $0.00 NoX
7. Ihave been released on bail in the amount of $0.00 0 Cash [] Surety Posted by: [1] Self [] Family [] Other
A person who knowingly provides false information to the clerk of the court in seeking a determination of indigent status under s. 27.52, F.S. commits a
misdemeanor of the first degree, punishable as provided in s. 775.082, F.S. I attest that the information provided on this Application is true and
accurate. nin
98/27/2021 (audibly Atestadby Datendangy [Distal Senedby
Signed SRS oT ST Te ae 8
ened’ on Signature of Applicant for Indigent Status
Print full name:
Date of Birth 7/24/85 Address: 9055 South Tamiami Trail Venice, FL, 34293
Phone: (941) 303-0983 Cell Phone:
Last four digits of Driver's License or ID Number Email Address:
CLERK'S DETERMINATION
Based on the information in the 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: August 27, 2021
Clerk of the Circuit Court
This form was completed with the assistance of : (Jennifer Cramer /
Jennifer Cramer
Clerk/Deputy Clerk/Other authorized person
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.
Document Filed Date
August 27, 2021
Case Filing Date
August 26, 2021
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IN THE CIRCUIT / COURT OF THE 20th JUDICIAL CIRCUIT IN AND FOR CHARLOTTE COUNTY, FLORIDA L- 4 24 O STATE OF FLORIDA vs. BOOKING NUMBER: 202104718 BAINE, CASEY JO DATE OF BIRTH: 7/24/1985 Affidavit for Indigent Status losure Form Pursuant to Rule 10-2.1 of the Rules Regulating the Florida Bar, before a nonlawyer assists a person in the completion of the Affidavit of Indigent Status, the nonlawyer shall provide the person with a copy of this disclosure. A copy of the disclosure, signed by both the nonlawyer and the person, shall be given to the person to retain and the nonlawyer shall keep a copy in the person's file. The disclosure does not act as or constitute a waiver, disclaimer, or limitation of liability. The Deputy Clerk/Pretrial Officer, whose signature appears below, will conduct a Pretrial interview and assist me with the Affidavit of Indigent Status. The Deputy Clerk/Pretrial Officer has told me and J understand that the Deputy Clerk/Pretrial Officer: Is not a lawyer; May not give legal advice or represent me in court; Cannot tell me what my rights or remedies are or how to testify in court; May only help me by asking me factual questions to fill in the blanks on the form; May also tell me how to file the form; May only help fill out a form that has been approved by the Supreme Court of Florida. I can read English 1 I cannot read English but this disclosure form was read to me by in (language), which J understand. You have been found to be_X__ INDIGENT “_NOT INDIGENT. The $50.00 application fee is to be paid tot! the Clerk of Court within 7 days or it will be added to any cost that may be assessed against you at the conclusion of your case. 169% ou have 68en found indigent, the Public Defender will represent you. You must contact them at 350 E. Marion Avenue, Room 109953] Bunta Gouda, FLY FY (941.637.2181) if released. If you are not released, they will contact you at the jail. If found not indigent you megstek ical eet review by asking for a hearing time. nm 2 aad 3c Sse Be Az dos xSz 9 ac aa cS 2 >a aN “114230. 08/27/2021 Signature of. Applicant Date / Jennifer Cramer / 08/27/2021 Signature of Deputy Clerk/Pretrial Services Officer DateIN THE CIRCUIT / COURT OF THE 20th JUDICIAL CIRCUIT IN AND FOR CHARLOTTE COUNTY, FLORIDA , Y-324-o STATE OF FLORIDA vs. BOOKING NUMBER: 202104718! BAINE, CASEY JO DATE OF BIRTH: 7/24/1985 APPLICATION FOR CRIMINAL INDIGENT STATUS 1 AM SEEKING THE APPOINTMENT OF THE PUBLIC DEFENDER OR (_=sI 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 judgement 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 the 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. I, Ihave Q dependants. (Do not include children not living at home and do not include a working spouse or yourself) 2. [have a take home income of $0.00 paid (Take home income equals salary, wages, bonuses, commissions, allowances, overtime, tips and similiar payments, minus deductions required by law and other court ordered support payments) 3. [have other income paid —_: (Circle "Yes” and fill in the amount if you have this kind of income, otherwise circle "No") Social Security benefits Yes $0.00 NoX _ Veterans’ benefit Yes $0.00 NoX Unemployment compensation YesX $900.00 No Child support or other regular support Yes $0.00 NoX Union Funds Yes $0.00 NoX from family members / spouse Workers compensation Yes $0.00 NoX Rental income Yes $0.00 NoX Trusts or gifts Yes $0.00 NoX __ Dividends or interest Yes 0.00 NoX Retirement / pensions ‘Yes $0.00 NoX — Other kinds of income not on the list Yes $0.00 NoX 4. [have other assets: (Circle "yes" and fill in the of the property, otherwise circle "No") Cash Yes $0.00 NoX — Savings Yes 0.00 NoX Bank account(s) Yes $0.00 NoX Stocks / bonds Yes $0.00 NoX Certificate of deposit or money Yes. $0.00 NoX *Equity in homestead real estate Yes $0.00 NoX market account(s) *Equity in non-homestead real estate *Equity in Motor vehicle(s) Yes $0.00 NoX include expectency ofan interest in such Yes £0.00 Nox *Equity in boats/ other tangible Yes $0.00 Nox Property Property 5. Ihave a total amount of liabilities and debts in the amount of $0.00 6. L receive: (Circle "Yes" or "No") Temporary Assistance for Need;y Families-Cash Assistance Yes $0.00 NoX Poverty- related veterans’ benefits ‘Yes $0.00 NoX Supplemental Security income (SSI) Yes $0.00 NoX 7. Ihave been released on bail in the amount of $0.00 0 Cash [] Surety Posted by: [1] Self [] Family [] Other A person who knowingly provides false information to the clerk of the court in seeking a determination of indigent status under s. 27.52, F.S. commits a misdemeanor of the first degree, punishable as provided in s. 775.082, F.S. I attest that the information provided on this Application is true and accurate. nin 98/27/2021 (audibly Atestadby Datendangy [Distal Senedby Signed SRS oT ST Te ae 8 ened’ on Signature of Applicant for Indigent Status Print full name: Date of Birth 7/24/85 Address: 9055 South Tamiami Trail Venice, FL, 34293 Phone: (941) 303-0983 Cell Phone: Last four digits of Driver's License or ID Number Email Address: CLERK'S DETERMINATION Based on the information in the 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: August 27, 2021 Clerk of the Circuit Court This form was completed with the assistance of : (Jennifer Cramer / Jennifer Cramer Clerk/Deputy Clerk/Other authorized person 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.