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MT “*** FILED: BROWARD COUNTY, FL Brenda D. Forman, CLERK 6/19/2017 1:49:07 PM.*#** IN THE GIRGUITICOUNTY COURT OF THE _ SEVENTEENTHL_JUDICAL CRCUIT Soe eae stig ophonba ve caseno. | FE OOTE, 72 VIO a Lrlero- Deter Ot Ss APPLICATION FOR CRIMINAL INDIGENT STATUS |AM SEEKING THE APPOINTMENT OF THE PUBLICDEFENDER OR __|HAVE A PRIVATE ATTORNEY OR AM SELF-REPRESENTED AND SEEK DETERMINATION OF INDIGENCE STATUS FOR COSTS Note to Applicant Th proven la pubic delendeicoutappoted lawyer nd cole process serces ae notes A ment and ken maybe mnpsed agant al el «personal roperty you onn pa olga and cher serces pred on your hal or on hal the person for whom yu are making ths appteabon Thee a $500 fee foreach appicabon Hed the applcatn esol padi the Geko the Cour wih 7 days, wil be ated o any casts hat may be assessed agans youat the concn of ‘case Iyou are parendguarian maang ths that on beta of amor or ax dependent aut, the oat contaned nts aplzaton mus nde your name and aes 1 Thave O dependents (Oo notincude chicren not hang at home and do not include a working spouse or yoursll) 2 have a take home income of $_()__ paid () weekly () brweekly ( } sememonthiy () monthiy() yearly (Take tome mcome equals salary, wages, onuses, cammesors,alowarces, overtime, ips and smi payment, minus dedcons requred by aw and other cout ordered ‘support peyments) 4 have other come par () weekly () b-weeky (} eem-menthy() monthly (}yeary (Crete "Yes" and iin the amount you have ts kn of came, oftenmse ele ‘No Soctal Secunty benetts Yes$. Veterans benett Yes$__ C ‘Unemployment compensation Yes$. Cua supporto ther reguiar support om ‘Unon funds Yes. family membersspouse Yes 8 Workers compensation Yes. Rental ncome Yes 8 Retrement/pensions Yes Daadends or interest Yes $ Trusts orgs Yes. ‘Otherknds of income notontheist Yes $ 4 Ihave other assets (Cycle ‘es" and filin the valve ofthe eae orcie‘No’) Cash Yess. Sang Yess. Bank acount) eee Stocksfbonds Yes$_ Cares of eat “Teun oneeodelesoto Yes roy mat somes ‘Eq atnovronesont eet Yes “cqay es § Fok artis ES ce eed an let sich opty si Seongeliaeun orgasm ein = ‘amount ot $_/Y, 1 Semaine eenioy we EE moans ye © tami ‘e 7 Uhave been released on bail in the amount of $_"2-<-» 2 Cash ‘Surety \ 7 Posted by Self, Family, Other. ‘Apetson wo knowngly proves false norman othe clerk or the court m secking a detrminaton of ndigent status under s 27 $2, FS, commis a misdemeanor of the rst degree, punshable as provided ms 75082, FS ors 775083, FS latest thatthe infosrton- Lave promided on this Applicaton is true and accurate —Bpnans ora ey aS Prntfulegalname Kennett Lut lcoro wairess KSAT ee A C333 Oty, Sate, 2F Vr acco. orl Nurber Phono number TW =~ ¥10 ~ 33 i ders hereby appomied an Dated nf Saye Ths form was completed wi the assslace of Gerben Conroe aatorcsipacon WEINSO W® | APPLICANTS FOUND NOT INDIGENT MAY SEEK REVIEW BY ASKING FOR A HEARING TIME Sign hero 1 you want tho judgo to review the clas decison of not indigent Fenda Supreme Cout For $984, Updatod 112915