, IN THE CIRCUIT COURT FOR THE FOURTH JUDICIAL CIRCUIT IN AND FOR DUVAL, CLAY AND NASSAU COUNTIES, F O "_'I ·

L E D AMENDED ADMINISTRATIVE ORDER NO. 95-5

ru MAR 0 6 2001

ru RE: PROCEDURES FOR CERTIFICATION OF INSOLVENCY 1

g' CIVIL DIVISIONS OF THE CIRCUIT COURT ;?·•-»Z·-·

Q p

nm ¤••••u•v ¤•u••v

Q WHEREAS, Section 57.081, Florida Statutes (2000) mandates that any indigent person

§ who is a party or intervenor in any judicial proceeding shall receive without charge certain services

.:6 from the clerks of the Circuit Court ( the ‘Clerk") and the sheriffs; and

WHEREAS, Section 57.081, Florida Statutes (2000) further mandates that prepayment of

costs to the Court, clerk, or sheriff is not required if the partyobtains from the Clerk a certification

of indigency; and

WHEREAS, Section 57.081, Florida Statutes (2000) permits the Clerk to issue a

certification of indigency if the party applying for such status ("applicant") files an affidavit that

includes a claim that he/she is indigent and unable to pay the charges otherwise payable by law,

provides details as to the financial condition of applicant, and a statement certifying that no person

has been paid or promised payment for services performed on behalf of the applicant in connection

with the proceeding; and

WHEREAS, pursuant to Section 57.081, Florida Statutes (2000), when a person is

represented by an attomey, such person need not file an affidavit in order to be exempt from the

payment of charges connected to an action or proceeding if the attorney files a written certificate,

signed by the attorney, certifying the attomey has made a determination the client is indigent, and

the attomey intends to provide legal services to the applicant without compensation; and

WHEREAS, it has come to the attention of the Court that abuses of Section 57.081,

Florida Statutes (2000) are occurring within this Circuit by persons unrepresented by legal counsel;

and

\ 2

to

, WHEREAS, it is the duty of the Court to prevent an abuse of judicial procedure.

Q. It is, hereby, ORDERED that:

l. Any party or intervenor who initiates a legal action or proceeding in this judicial

:1 circuit may seek a waiver from prepayment of court charges, costs and fees because of indigency.

D.

Upon such request by the party or intervenor, the Clerk shall issue to the applicant a certification

§ of indigency in order for the case to proceed.

ZL 2. The Clerk shall stamp, or otherwise indicate, on the Court case file that a person

ig involved with the case is seeking indigent status.

3. The Clerk shall provide to the applicant, an Affidavit of Indigency form and a |y Law Financial Affidavit (Short Form) that must be completed and signed by the applicant, and

filed with the Clerk at the time of the initial filing. (Q, Florida Supreme Court Approved

Family Law Forml2.902(a), Affidavit of indigency, and Florida Family Law Rules of Procedure

Form l2.902(b), Family Law Financial Affidavit (Short Form), which are incorporated herein as

Attachment A and Attachment B, respectively)

4. The completed Affidavit of lndigency and Family Law Financial Affidavit {Short

Ecgi) must be accompanied by any document(s) that will verify the income of applicant.

5. Within seven (7) days alier the filing of applicant’s case, the Clerk shall forward the

applicant’s request for certification of indigency, and supporting documentation, to the assigned

Judge for consideration, if it appears the applicant’s income is 25% above the current federal

poverty standards. Current standards are incorporated herein as Attachment C, and may be

modified in the future by Administrative Order. (gg, Jacksonville Area Legal Aid, Inc.,

Financial Eligibility Standards, March 2000, Attachment C.)

7. The applicant is entitled to a review by the Court of his/her application for indigent

status if thc Clerk fails to or refuses to issue a certificate of indigency.

_ 8. At the J udge’s discretion, the applicant’s

request for indigency status may be set for a

(S

hearing.

9. lf a hearing on the issue is not required, the Judge shall make a determination as to

:1 whether the applicant’s request for indigency

status should be granted, based on the financial

In affidavit and the other documentation submitted by

applicant. If the Judge determines the

applicant is not indigent, the Judge shall issue an Order revoking the applicant’s initial

jg certification of indigency. Within seven (7) days

of service of the revocation Order, applicant

ig shall pay to the Clerk any charges that had been deferred at the time of applicant’s initial filing.

lf the appropriate charges are not paid to the Clerk by the applicant in a timely manner, the

applicant’s cause shall be automatically dismissed without prejudice.

10. The terms hereof shall not apply to parties or intervenor who are represented by legal

counsel, provided said counsel files a certificate as required by Section 57.081, Florida Statutes

(2000).

ll. This Administrative Order does not apply to cases filed in Circuit Court pursuant to

Section 741.30 and Section 784.046, Florida Statutes (2000), pertaining to matters of domestic

violence.

l2. lf an applicant prevails in an action, costs shall be taxed in his/her favor, as provided

by law, and when collected, shall be used to pay costs which otherwise would have been

required

and which have not been paid.

DONE AND ORDERED at Jacksonville, Duval County, Florida, this 2* L day of

2001.

CHIEF JUDGE

IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT, IN AND FOR COUNTY, FLORIDA

ul

33 Case No.: M Division:

ll.!

: Petitioner,

D.

and

1*

g gn Respondent.

1 S

AFFIDAVIT OF INDIGENCY Dil

1, {full legal name} , being sworn, certify that the following

statements are true:

I am financially insolvent and unable to pay the charges, costs, or fees otherwise payable by law to the clerk of the circuit court or sheriff in this civil action. I make this claim because:

[ J` one only]

__ a. I am currently receiving public assistance in the amount of $ per ( ) week ( ) month.

My public assistance case numberis: . My financnl aiiidavit, %D Florida Family Law Rules of Procedure Form l2.902(b), is attached. b. I am tmable to pay those clerk’s fees and costs because of indigency, based on facts contained in my Family Law Financial Affidavit, QD Florida Family Law Rules of Procedure Form l2.902(b), which is attached.

I CERTIFY THAT NO PERSON HAS BEEN PAID OR PROMISED ANY PAYMENT OF ANY REMUNERATION BY ME FOR SERVICES PERF ORMED ON MY BEHALF IN CONNECTION WITH THIS ACTION OR PROCEEDING.

I certify that a copy of this document was [J. one only] ( ) mailed ( ) faxed and mailed ( ) hand

delivered to the person(s) listed below on {date} .

Other party or his/her attorney: Name; Address:

City, State, Zip:

Fax Number:

I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this affidavit and that the punishment for knowingly making a false statement includes fines

and/or imprisonment.

Dated:

Signature of Party Printed Name:

Address:

City, State, Zip:

ATTACHMENT A `

Telephone Number:

Fax Number:

l`~

ul¢N

g` STATE OF FLORIDA

*5 COUNTY OF CL

ql Sworn to or affirmed and signed before me on by .

O Ch Ch

gg NOTARY PUBLIC or DEPUTY CLERK

ON

[Print, type, or stamp cormnissioned name of notary or clerk.]

Personally known Produced identification

Type of identification produced

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW: [ mn fill in all blanks] I, {full legal name and trade name afnonlawyer} ,

a nonlawyer, located at {stree§ , {city} ,

{state} , Qahone} ,helped {name} ,

who is the [ J- one only] __ peiitioner 0r _ respondent, fill out this fonsn.

Florida Supreme Court Approved Family Law Form l2.902(a), Affidavit oflndigency

IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,

3 IN AND FOR COUNTY, FLORIDA *1*

N Case No.:

m Division: ¤"

gf Petitioner,

and

'¢

0 Respondent.

'§ FAMILY LAW FINANCIAL AFF IDAVIT (SHORT FORM) Lg

(Under $50,000 Individual Gross Annual Income)

L UuUleg¤lm1m¢}|, being swom, certify that the following information is true:

My Occupation: Employed by:

Business Address;

Pay rate: S __|( ) every week ( ) every other week ( ) twice a month ( ) monthly ( ) other: D Check here if unemployed and explain on a separate sheet your efforts to find employment.

SECTION I. PRESENT MONTHLY GROSS INCOME: All amounts must be MONTHLY. See the instructions with this fomi to figure out money amounts for anything that is NOT paid monthly. Attach more paper, if needed. Items included under "other" should be listed separately with separate dollar amounts.

l. Monthly gross salary or wages l. S 2. Monthly bonuses, commissions, allowances, overtime,tips, and similarpayments 2.

3. Monthly business income from sources such as selfiemployment, partnerships, close corporations, and/or independent contracts (gross receipts minus ordinary and necessary expenses required to produce income) (D Attach sheet itemizing

such income and expenses.) 3.

4. Monthly disability benefits/SSI 4.

5. Monthly Workers’ Compensation 5.

6. Monthly Unemployment Compensation 6.

7. Monthly pension, retirement, or annuity payments 7.

8, Monthly Social Security benefits 8_

9. Monthly alimony actually received

9a. From this case: $

9b. From other case(s): Add 9a and 9b 9.

l0. Monthly interest and dividends l0.

ll. Monthly rental income (gross receipts minus ordinary and necessary expenses required to produce income) (El Attach sheet itemizing such income and expense

items.) ll.

l2. Monthly income from royalties, trusts, or estates I2.

I3. Monthly reimbursed expenses and in·kind payments to the extent that they reduce personal living expenses I3.

14. Monthly gains derived from dealing in property (not including nonrecurring gains) I4.

I5. Any other income ofa recurring nature (list source) l6. I5.

I6.

ATTACHMENT B

17. PRESENT MONTHLY GROSS INCOME (Add lines 1-16) TOTAL: 17. S

U* PRESENT MONTHLY DEDUCTIONS: Eg 18. Monthly federal, state, and local income tax (corrected for filing status and

gu allowable dependents and income tax liabilities) a. Filing Status

2, b. Number ofdependents claimed i3_ $

eg 19. Monthly FICA or self-employment taxes l9.

CL 20. Monthly Medicare payments 20.

21. Monthly mandatory union dues Zl.

·q· 22, Monthly mandatory retirement payments 22,

O 231 Monthly health insurance payments (including dental insurance), excluding

portion paid for any minor children ofthis relationship 23,

24. Monthly court-ordered child support actually paid for children from another .1 relationship 24.

25. Monthly court-ordered alimony actually paid

on 25a. from this case: S 25b, from other case(s); Add 25a and 25b 25.

26. TOTAL DEDUCTIONS ALLOWABLE UNDER SECTION 61.30, FIDRIDA STATUTES (Add lines 18 through 25) TOTAL: 26.S

zéziférhliiétiijrf Z =¥F=Ys"j¤?5=;.z;!;==si;¥ . .v.==::;,E=¤5$> =.f;.E:=

‘ — Iii}: ;z— z.;

;

SECTION I]. AVERAGE MONTHLY EXPENSES

A. HOUSEHOLD: Other: S

Mortgage or rent S

Property taxes S Utilities S _..__....._ Telephone S

Food S

Meals outside home S

Maintenance/Repairs S

Other: S

B. AUTOMOBILE Gasoline S

Repairs S

Insurance S

C. CHILD(REN)’S EXPENSES Day care S

Lunch money S

Clothing S

Grooming S Gif`ts for holidays S

Medical/dental (uninsured) S

Other: S

D. INSURANCE Medical/dental S

Chi|d(ren)’s medical/dental S Life S

Florida Family Law Rules of Procedure Fomi l2.902(b), Family Law Financial Affidavit (Short Form) (9/00)

E. OTHER EXPENSES NOT LISTED ABOVE Clothing $

Medical/Dental (uninsured) $

E Grooming $ q- Entertainment $ _|___ (U Gills $

N Religious organizations $

gt Miscellaneous $

*6 Other: $° ___. s __ ____..__ $ ...? U, |_._._ $|... cn .|... $_.

. ...|... $ |..

%g F. PAYMENTS T0 CREDITORS Mowrmv

CREDITOR: PAYMENT _.._.. $1.. _..._. $ ....._.

_.....? $ ...| _..; $ ..1 é..... $ ...; _.... $ _;.. |..... 5......

28. TOTAL MONTI-H.Y EXPENSES (add ALL monthly amounts in A through F above) 28.$

SUMMARY Z9. TOT AL PRESENT MONTHLY NET INCOME

(from line 27 of SECTION I. INCOME) 29. $

30. TOTAL MONTHLY EXPENSES (from line 28 above) 30. S

31. SURPLUS (Ifline 29is more than line 30, subtract line 30 from line 29.

This is the amount of your surplus. Enter that amount here.) 3I. $

32. (DEFICIT) (If line 30 is more than line 29, subtract line 29 from line 30.

This is the amount ofyour deficit. Enter that amount here.) 32. (S l

SECTION III. ASSETS AND LIABILITIES Use the nonmarital column only If this is a petition for dissolution of mG40

arringe and you believe an item ls "nonm¤rIt¤l," meaning it belongs to only one of you and should not be divided. You

should indicate to whom you believe the item(s) or debt belongs. (Typically, you will only use this column if property/debt was ovimed/owed by one spouse before the marriage. See the "General Information for Self-Represented Litigants" found at the

beginning of these forms and section 61 .075( 1), Florida Statutes, for definitions of "marital" and "nonmarital" assets and liabilities.)

A. ASSETS:

Florida Family Law Rules of Procedure Fonn l2.902(b), Family Law Financial Affidavit (Short Form) (9/00)

--4 ifthkébuitinaxttcéviui Qtlwi `ouizrI E| Cash <<>¤ md)

¤ Cash in banks or credit unions E1 Stocks, Bonds, Notes

:1 El Real estate: Home ‘* ¤ Other {X1 _'

D Automobiles

O U OIl1€l' |SISDHHI |FO|B

g D Retirement |lans Proiit Sharin|, Pension, IRA, 401 k s, etc.

J; ¤ Other

3 its

EI if here if additional pages are attached. I |-

3 i ;

1 ci

Florida Family Law Rules of Procedure Fcnn l2,902(b), Family Law Financial Affidavit (Short Form) (9/00)

s. LIABILITIES:

~1- E| ··

zssuws;i"st¢2,s1assIz1Iss‘s¤‘ i|snsieslt it S 2:;

on real

Aw ·¤ |11 tx .

El Char|e/credit card accounts

,,

g |- Q El

It¤

g |-- a |--

D

E1 if here if additional |a|es are attached.

iééiélis.éST*ift.YIEFEE €¥¥iYZ-%$¥¥?,¥$??*$%%‘PITE?¥?i?*¥?$--·~·~·--~ ?°¥i“?*‘?1°`?”°i —Yi’i`|

c. commcnm Assms AND LIABILITIES: INSTRUCTIONS: If you have any POSSIBLE assets (income potential, accrued vacation or sick leave, bonus, inheritance, etc.) or POSSIBLE liabilities (possible lawsuits, future unpaid taxes, contingent tax liabilities, debts assumed by another), you must

llatrltervm-.

.li€ii;»§ viI-:lSiZ’Z ei {ia;";j—;»%;‘Q,:;L5 |_ {QEr-X-1;J;i:·i=E=2z-4;giii‘;sZ·=·xt;vii»?J1;‘ii»;2;;;;i`E-pzs;2eit2*1,2,g=;.-j-j zz,;£vs¤1¤I¢=Ye¥@*é2,

{ "¥*€‘¥*?* W'?Fl?lll?%?·?*l?l@?§§F!¥$*%¥?€*®%‘Y¤l*¢'#i%WQ¤¥—¤lié?~¥¢?i%§€*?l§is§§l%¢Z3s!s¢ -

3 3.; iii;

» 1Y E -;§:§ |as| ¥¥|1¥Y|*|T|é|f|i .¥¥2~,i¤|i I 5| ix

%__ ji-,Q;fz,jEf;§g2§;QgQj}gg?r3Q

= jj f:YEjQ§,;,§,;;j ’§

Qi; YQ_§,§ Qj |Qs; fQ

—¤ i zisééxtzvr ·‘

if WE

Total Contingent Liabilities

SECTION IV. CHILD SUPPORT GUIDELINES WORKSHEET (NCI Florida Family Law Rules of Procedure Form l2.902(e), Child Support Guidelines Worksheet, MUST be tiled with

Florida Family Law Rules ot" Procedure Form l2.902(b), Family Law Financial Affidavit (Short Form) (9/00)

the court at or prior to a hearing to establish or modify child support. This requirement cannot be waived by the parties.) gv; [

J- one only]

V; A Child Support Guidelines Worksheet IS or WILL BE filed in this case. This case involves gu the establishment or modification of child support.

W A Child Support Guidelines Worksheet IS NOT being filed in this case. The establishment

:1 or modification of child support is not an issue in this case.

CL . . . .

1 cemfy that a copy of this document was [ J` one only] ( )ma1led( )faxed and ma1led( )hand

_¢ delivered to the pe1son(s) listed below on {date} .

O g Other party or his/her attorney:

Name:

-é Address:

g City, State, Zip: Q Fax Number:

I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this affidavit and that the punishment for knowingly making a false statement includes fines and/or imprisonment.

Dated:

Signature of` Party

Printed Name;

Address:

City, State, Zip;

Telephone Number:

Fax Number:

STATE OF FLORIDA COUNTY OF

Swom to or affirmed and signed before me on by .

NOTARY PUBLIC or DEPUTY CLERK

[Print, type, or stamp commissioned name of notary or deputy clerk.]

Personally known Produced identification

Type of identification produced

Florida Family Law Rules ofProcedure Form l2,902(b), Family Law Financial Affidavit (Short Fonn) (9/00)

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE BLANKS BELOW: [ lm fill i.n all blanks] I, {full legal name and trade name afnanlawyer}

,

: a nonlawyer, located at {street} , {city} ,

gl {state} , Qahane} , helped {name} ,

who is the [J one only] _ petitioner or ___ respondent, fill out this form. 2. *6

CL

·¤'

O 0* U*

Ji00N

Florida Family Law Rules of Procedure Form l2.902(b), Family Law Financial Affidavit (Short Fom1) (9/00)

qc %O01051736 Buell: 904

, JACKSONVILLE AREA LEGAL AID, INC. °4g¤5= @463 — 2475 F1 ed & Recorded

03F/Off-@001 04:03:03 PH

I0 Fmadcmi Eiagaminy Standards mum DLWAL COUNTY

‘” Mami, 2000 ua

The standards applied are 25% above the current federal poverty standards and are within the range pernitted by the Legal Services Corporation regulation on this subject. The

{ amounts stated are maximums of gross income.O g FAMILY SIZE WEEKLY MONTHLY ANNUALLYx S I $200.73 $ 869.83 $ 10,438.00 0:

2 270.44 1,171.92 14,063.00

3 340.15 1,474.00 17,688.00

4 409.87 1,776.08 21,313.00

5 479.58 2,078.17 24,938.00

6 549.29 2,380.25 28,563.00

7 619.00 2,682.33 32,188.00

8 688.71 2,984.42 35,813.00

For family units with more than eight (8) members, add $69.71 weekly, $302.08 monthly, or

$3,625.00 annually for each additional member in a family

Persons age 60 or over may be entitled to program service even if they have income in excess ofthe above guidelines, if the cost of the needed legal service is beyond their ability to pay. Clients under Fair Housing, Ryan White, and some other grant funding may also be exempt from strict application of these guidelines.

In addition to income guidelines, clients may not exceed the maximum of $2,000 in assets.

Note: Methods used to calculate Household Monthly Income on Page I of the JALA Application.

Income paid weekly is multiplied by 4.3

Income paid twice a month is multiplied by 2 Income paid every two weeks is divided by 2 and then multiplied by 4.3

Annual income is divided by l2.

ATTACHMENT C