IN THE CIRCUIT COURT, SIXTH JUDICIAL CIRCUIT
IN AND FOR
ADMINISTRATIVE ORDER NO. 2005-001 PA/PI-CIR
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RE: INMATE INDIGENCE ELIGIBILITY
In order to more effectively comply with the requirements of section 57.085, Fla. Stat., and to update the forms based upon statutory changes, it is hereby
ORDERED:
1.
Any prisoner who initiates or intervenes in a judicial proceeding and
seeks to defer the prepayment of court costs and fees must file an affidavit of
indigence with the Clerk of Court. The
affidavit must contain the information included in the attached Affidavit of
Indigent Status.
2.
Any prisoner who initiates or intervenes in a judicial proceeding and
seeks to defer the prepayment of court costs and fees must also file an
Affidavit of Prior Litigation by Prisoner.
The Affidavit must contain the information included in the attached
Affidavit of Prior Litigation by Prisoner.
3.
When a prisoner seeks to defer the prepayment of court costs the Clerk
of Court shall review the Affidavit of Indigence and the Affidavit of Prior
Litigation by Prisoner before the case can be filed. The Clerk shall indicate on the Order on
Inmate Indigence Eligibility whether the prisoner has been determined to be
indigent at least twice in the preceding three years and whether the prisoner
appears to be indigent.
4.
The attached Order on Inmate Indigence Eligibility shall be presented by
the Pinellas Clerk of Court to a Civil Administrative Judge and by the
5.
The attached Order on Inmate Indigence Eligibility may be modified by
the Court without further modification to this administrative order.
DONE AND ORDERED
in Chambers at
______________________________
David
A. Demers, Chief Judge
cc: All Judges
The Honorable
The
Honorable
The Honorable
The Honorable
Betty Henderson, Assistant Court
Services
Gay Inskeep, Trial Courts Administrator
Bar Associations,
Law Libraries,
IN THE
IN AND FOR
____________________________,
Plaintiff/Petitioner
vs. Ref. No.: _____________________
UCN: _____________________
____________________________,
Defendant/Respondent.
AFFIDAVIT OF INDIGENT STATUS
I, _____________________________ (full legal name) state the following in support of my application for deferral of prepayment of costs and fees pursuant to Section 57.085, Florida Statutes:
1.
I
have ______dependents. (Do
not include children not living at home and do not include working spouses.) Their names and ages are listed below:
_________________________________________________________________
_________________________________________________________________
2. I have take-home income of
$________________ paid
____ weekly ______ bi-weekly (every two weeks)
____ semi-monthly (twice a month) ______ monthly
(Take-home
income equals salary, wages, bonuses, commissions, allowances, overtime, tips
and similar payments minus deductions required by law and other
court-ordered payments.)
3. I
have $_____________ in other annual income: (Circle “Yes” and fill in
the amount if you have this kind of income or check “No” if you do not have
this kind of income)
Social Security
benefits Yes
$_________ No_______
Unemployment
compensation 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_______
4.
I
have $_______________ in other assets. (Circle “Yes” and fill in the value of the property or check “No” if
you do not have this kind of property.)
Cash Yes
$_________ No_______
Savings Yes
$_________ No_______
Bank account(s) 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: (Check “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 a previous case
where I was the defendant within the past year.
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_____
9. I have the following debts:
Name of Creditor Security Balance Monthly Payment
____________________ _________ ________
_____________
____________________ _________ ________
_____________
____________________ _________ ________ _____________
____________________ _________ ________
_____________
____________________ _________ ________
_____________
____________________ _________ ________
_____________
10.
In
addition to the monthly payments listed above, I have the following other
monthly expenses (list
here such things as utilities, child support or alimony, rent, or anything else
you pay month-to-month)
Monthly
Expense Amount
______________________________ __________
______________________________ __________
______________________________ __________
______________________________ __________
______________________________ __________
______________________________ __________
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 No.: ________________________________________
Sworn to or
affirmed and signed before me this _________ day of ___________, 20____, by
_____________________________, who is personally known to me or who produced
__________________________ as identification.
_________________________________
NOTARY
PUBLIC
Print
Name: ______________________
My
Commission Expires: ____________
IN THE
IN AND FOR
____________________________,
Plaintiff/Petitioner
vs. Ref. No.: ______________________
UCN: ______________________
____________________________,
Defendant/Respondent.
______________________________________/
AFFIDAVIT OF PRIOR LITIGATION BY PRISONER
I, _______________________________________ (full legal name), state the following in support of my application to defer the prepayment of court costs and fees in the above matter pursuant to Section 57.085, Florida Statutes:
1. I have been convicted of a crime and am currently incarcerated for that crime or I am being held in custody pending extradition or sentencing.
2. (Check one)
_____ I am an intervenor in the above-styled judicial proceeding.
_____ I initiated the above-styled judicial proceeding.
3. I am a pro se litigant and am not represented by an attorney.
4. I certify that I have neither paid nor promised to pay anyone for services on my behalf in connection with this judicial proceeding.
5. I am presently unable to pay court costs and fees otherwise payable by law to the court, clerk and sheriff for their services. Therefore, I am applying for a deferral of prepayment of costs and fees pursuant to Section 57.085, Florida Statutes.
6. I have previously been adjudicated indigent under Section 57.085, Florida Statutes (prisoner indigence). ________ Yes _________ No
7. I have previously been adjudicated indigent under Section 57.081, Florida Statutes (civil indigence). ________ Yes _________ No
8. I have previously been authorized to proceed as an indigent under 28 U.S.C. § 1915 by a federal court. ________ Yes _________ No
If you answered “yes” to questions 6, 7 or 8, list below all suits, actions, claims, proceedings, or appeals, including dates, which you brought or in which you intervened in any court or other adjudicatory forum within the past five years.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
9. Attached and incorporated into this Affidavit is a photocopy of my trust account records for the preceding six months or the length of my incarceration, whichever is shorter.
10. Attached and incorporated into this Affidavit is my Affidavit of Indigence.
11. I am presently unable to pay court costs and fees. Under penalty of perjury, I swear or affirm that all statements in this affidavit are true and complete.
NOTARIZED OATH
I, _________________________ (full legal
name), being first duly sworn, state under oath and under penalty of
perjury that all statements in this Affidavit are true and complete.
_________________________________
Signature of Applicant for Indigent Status
Date Signed
______________________
PRINT Full Legal
Name ________________________________________
Address ________________________________________
Driver’s License #
or ID # ________________________________________
Date of Birth ________________________________________
Telephone No.: ________________________________________
Sworn to or
affirmed and signed before me this _________ day of ___________, 20____, by
_____________________________, who is personally known to me or who produced
__________________________ as identification.
_________________________________
NOTARY
PUBLIC
Print
Name: ______________________
My
Commission Expires: ____________
IN THE
IN AND FOR
_________________________
Plaintiff/Petitioner,
Ref No:___________________________
v. UCN:___________________________
__________________________
Defendant/Respondent.
__________________________________/
ORDER
ON INMATE INDIGENCE ELIGIBILITY
AND
JUDICIAL REVIEW OF COMPLAINT
THIS CAUSE came before the court pursuant to the requirements of §57.085, Florida Statutes. Accordingly, the court finds and orders as follows:
I. PRIOR INDIGENCE DETERMINATIONS
(This paragraph to be completed by the Clerk) The Plaintiff/Petitioner _______has/ ______has not (check one) at least twice in the preceding three years been adjudicated indigent for purposes of prepayment of court costs and fees, and has______ / has not ______ (check one) attached a complete listing of each suit, action, claim, proceeding or appeal brought by or intervened in by the inmate in any court in the preceding five years. Failure to attach said listing where applicable shall result in dismissal of the claim.
(If the
Plaintiff/Petitioner has not at least twice in the preceding three years
been adjudicated indigent for purposes of prepayment of court costs and fees, continue
to section II).
The Plaintiff/Petitioner has at least
twice in the preceding three years been adjudicated indigent for purposes of
prepayment court costs and fees. Upon review of the above and
Plaintiff/Petitioner’s attached listing the court GRANTS______ / DENIES_______
(check one) leave to proceed in this matter. (If granted, continue to
Section II.)
(If denied, state
reason(s) below):
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
II. DETERMINATION OF INDIGENCE (check one):
(This sentence to be completed by the Clerk). The Plaintiff/Petitioner_____appears ______does not appear to be indigent.
(_) A. The Plaintiff/Petitioner is not found indigent and is ineligible for deferral of prepayment of court costs and fees in this action. Plaintiff/Petitioner must pay these costs and fees in full within 10 days of the date of this order or the case will be dismissed. (If Plaintiff/Petitioner is not indigent, continue to signature).
(_) B. The
Plaintiff/Petitioner is found indigent and eligible for deferral as follows: (If
B., check below and then continue to
Section III.)
_____ 1) Prepayment required. Plaintiff/Petitioner is required to pay to the clerk $_____ prior to service of process. This amount represents at least 20 percent of the average monthly balance of the Plaintiff/Petitioner’s trust account for the preceding six months or for the length of the Plaintiff/Petitioner’s incarceration, whichever period is shorter. There shall be a lien for the remaining unpaid costs and fees placed on the inmate’s account, and monthly deductions will be made from the inmate’s account by the Department of Corrections, the Sheriff’s office or such other entity managing this account, and sent to the Clerk of the Court towards these costs and fees. Such deductions shall be no less than 20% of the monthly balance of the inmate’s trust account, shall occur when the balance exceeds $10, and shall continue until full payment is made. Any dismissal of this case in the future shall not extinguish this lien.
______ 2) Prepayment not required. Plaintiff/Petitioner does not have to provide an initial partial payment of the court costs and fees. There shall be a lien for these costs and fees placed on the inmate’s account, and monthly deductions will be made from the inmate’s account by the Department of Corrections, the Sheriff’s office or such other entity managing this account, and sent to the Clerk of the Court towards these costs and fees. Such deductions shall be no less than 20% of the monthly balance of the inmate’s account, shall occur when the balance exceeds $10, and shall continue until full payment is made. Any dismissal of this case in the future shall not extinguish this lien.
III. JUDICIAL
REVIEW OF PETITION/COMPLAINT: (If
Plaintiff/Petitioner is indigent
check one):
(__) A. The court finds Plaintiff/Petitioner’s claim is sufficient to state a cause of action for which the court has jurisdiction and may grant relief
(__) B. The court finds:
Plaintiff/Petitioner’s
claim fails to state a claim for which relief may be granted and Plaintiff/Petitioner’s
claim is dismissed.
Plaintiff/Petitioner’s
claim seeks monetary relief from a defendant/respondent who is immune from such
relief and Plaintiff/Petitioner’s claim is dismissed.
Plaintiff/Petitioner’s claim
seeks relief for mental or emotional injury where there has been no related
allegation of a physical injury and Plaintiff/Petitioner’s claim is dismissed.
Plaintiff/Petitioner’s claim is
frivolous, malicious, or reasonably appears to be intended to harass one or
more named defendant/respondents and Plaintiff/Petitioner’s claim is dismissed.
No
rehearing of this order will be
entertained.
DONE
AND ORDERED in Chambers, at ____________________, Pasco/Pinellas County,
___________________________________
Judge