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\par }}{\*\aftnsepc \ltrpar \pard\plain \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af0\afs28\alang1025 \ltrch\fcs0 \fs28\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid6357401 \chftnsepc 
\par }}\ltrpar \sectd \ltrsect\psz1\pgnid\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid7233205\sftnbj {\headerl \ltrpar \pard\plain \ltrpar\s22\ql \li0\ri0\widctlpar\tqc\tx4680\tqr\tx9360\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 
\rtlch\fcs1 \af0\afs28\alang1025 \ltrch\fcs0 \fs28\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6712818 
\par }}{\headerr \ltrpar \pard\plain \ltrpar\s22\ql \li0\ri0\widctlpar\tqc\tx4680\tqr\tx9360\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af0\afs28\alang1025 \ltrch\fcs0 \fs28\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {
\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6712818 
\par }}{\footerl \ltrpar \pard\plain \ltrpar\s15\ql \li0\ri0\widctlpar\tqc\tx4680\tqr\tx9360\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af0\afs28\alang1025 \ltrch\fcs0 \fs28\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {
\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6712818 
\par }}{\footerr \ltrpar \pard\plain \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid14119039 \rtlch\fcs1 \af0\afs28\alang1025 \ltrch\fcs0 \fs28\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {
\rtlch\fcs1 \af0\afs16 \ltrch\fcs0 \fs16\insrsid6712818\charrsid5379757 Rev. }{\rtlch\fcs1 \af0\afs16 \ltrch\fcs0 \fs16\insrsid6712818 11/25/2007}{\rtlch\fcs1 \af0\afs16 \ltrch\fcs0 \fs16\insrsid6712818\charrsid5379757 
\par Developed by the Florida Clerks of the Court Ope}{\rtlch\fcs1 \af0\afs16 \ltrch\fcs0 \fs16\insrsid6712818 rations Corporation on 11/25/2007}{\rtlch\fcs1 \af0\afs16 \ltrch\fcs0 \fs16\insrsid6712818\charrsid5379757 
\par }\pard\plain \ltrpar\s15\ql \li0\ri0\widctlpar\tqc\tx4680\tqr\tx9360\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af0\afs28\alang1025 \ltrch\fcs0 \fs28\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid6712818 
\par }}{\headerf \ltrpar \pard\plain \ltrpar\s22\ql \li0\ri0\widctlpar\tqc\tx4680\tqr\tx9360\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af0\afs28\alang1025 \ltrch\fcs0 \fs28\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {
\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6712818 
\par }}{\footerf \ltrpar \pard\plain \ltrpar\s15\ql \li0\ri0\widctlpar\tqc\tx4680\tqr\tx9360\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af0\afs28\alang1025 \ltrch\fcs0 \fs28\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 
{\field{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \cs16\insrsid6712818  PAGE }}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 \cs16\lang1024\langfe1024\noproof\insrsid6712818 - 6 -}}}\sectd \ltrsect\pgnid\linex0\endnhere\sectdefaultcl\sftnbj {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid6712818 
\par }}{\*\pnseclvl1\pnucrm\pnstart1\pnindent720\pnhang {\pntxta .}}{\*\pnseclvl2\pnucltr\pnstart1\pnindent720\pnhang {\pntxta .}}{\*\pnseclvl3\pndec\pnstart1\pnindent720\pnhang {\pntxta .}}{\*\pnseclvl4\pnlcltr\pnstart1\pnindent720\pnhang {\pntxta )}}
{\*\pnseclvl5\pndec\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl6\pnlcltr\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl7\pnlcrm\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl8
\pnlcltr\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl9\pnlcrm\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}\pard\plain \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\faauto\outlinelevel0\rin0\lin0\itap0\pararsid1342205 \rtlch\fcs1 
\af0\afs28\alang1025 \ltrch\fcs0 \fs28\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \ab\af39\afs16 \ltrch\fcs0 \b\f39\fs16\insrsid1342205\charrsid1342205 IN THE CIRCUIT/COUNTY COURT OF THE ------------------ JUDICIAL CIRCUIT
\par IN AND FOR ---------------- COUNTY, {\*\xmlopen\xmlns2{\factoidname place}}{\*\xmlopen\xmlns2{\factoidname State}}FLORIDA{\*\xmlclose}{\*\xmlclose}
\par }\pard \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0\pararsid1342205 {\rtlch\fcs1 \ab\af39\afs16 \ltrch\fcs0 \b\f39\fs16\insrsid1342205\charrsid1342205 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0\pararsid1342205 {\rtlch\fcs1 \ab\af39\afs16 \ltrch\fcs0 \b\f39\fs16\insrsid1342205\charrsid1342205 ____________}{\rtlch\fcs1 \ab\af39\afs16 \ltrch\fcs0 \b\f39\fs16\insrsid1342205 
_________________________ \tab \tab \tab \tab \tab }{\rtlch\fcs1 \ab\af39\afs16 \ltrch\fcs0 \b\f39\fs16\insrsid1342205\charrsid1342205 CASE NO.______________________
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\outlinelevel0\rin0\lin0\itap0\pararsid1342205 {\rtlch\fcs1 \ab\af39\afs16 \ltrch\fcs0 \b\f39\fs16\insrsid1342205\charrsid1342205 Plaintiff/Petitioner or In the Interest Of
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0\pararsid1342205 {\rtlch\fcs1 \ab\af39\afs16 \ltrch\fcs0 \b\f39\fs16\insrsid1342205\charrsid1342205 vs.
\par ______________________________________
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\outlinelevel0\rin0\lin0\itap0\pararsid1342205 {\rtlch\fcs1 \ab\af39\afs16 \ltrch\fcs0 \b\f39\fs16\insrsid1342205\charrsid1342205 Defendant//Respondent
\par }\pard \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\faauto\outlinelevel0\rin0\lin0\itap0\pararsid1342205 {\rtlch\fcs1 \ab\af39\afs20 \ltrch\fcs0 \b\f39\fs20\ul\insrsid1342205\charrsid1342205 APPLICATION FOR DETERMINATION OF CIVIL INDIGENT STATUS
\par }\pard \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0\pararsid1342205 {\rtlch\fcs1 \ab\af39\afs20 \ltrch\fcs0 \b\f39\fs20\ul\insrsid1342205\charrsid1342205 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0\pararsid1342205 {\rtlch\fcs1 \ab\af39\afs18 \ltrch\fcs0 \b\f39\fs18\insrsid1342205\charrsid1342205 Notice to Applicant: }{\rtlch\fcs1 \af40\afs18 \ltrch\fcs0 
\f40\fs18\insrsid1342205\charrsid1342205 If you qualify for civil indigence you must enroll in the clerk\rquote s office payment plan and pay a one-time administrative fee of $25.00.  T
his fee shall not be charged for Dependency or Chapter 39 Termination of Parental Rights actions.
\par }{\rtlch\fcs1 \af40\afs16 \ltrch\fcs0 \f40\fs16\insrsid1342205\charrsid1342205 
\par 1. }{\rtlch\fcs1 \ab\af39\afs16 \ltrch\fcs0 \b\f39\fs16\insrsid1342205\charrsid1342205 I have ______dependents. }{\rtlch\fcs1 \ai\af41\afs16 \ltrch\fcs0 \i\f41\fs16\insrsid1342205\charrsid1342205 
(Include only those persons you list on your U.S. Income tax return.)
\par }{\rtlch\fcs1 \ai\af41\afs16 \ltrch\fcs0 \f41\fs16\insrsid1342205 \tab Are you Married?...Yes\'85.No\tab }{\rtlch\fcs1 \ai\af41\afs16 \ltrch\fcs0 \f41\fs16\insrsid1342205\charrsid1342205 Does your Spouse Work?...Ye}{\rtlch\fcs1 \ai\af41\afs16 \ltrch\fcs0 
\f41\fs16\insrsid1342205 s\'85.No      }{\rtlch\fcs1 \ai\af41\afs16 \ltrch\fcs0 \f41\fs16\insrsid1342205\charrsid1342205 Annual Spouse Income?   $_____________
\par }{\rtlch\fcs1 \ai\af41\afs16 \ltrch\fcs0 \i\f41\fs16\insrsid1342205\charrsid1342205 
\par }{\rtlch\fcs1 \af40\afs16 \ltrch\fcs0 \f40\fs16\insrsid1342205\charrsid1342205 2. }{\rtlch\fcs1 \ab\af39\afs16 \ltrch\fcs0 \b\f39\fs16\insrsid1342205\charrsid1342205 I have a net income of $_______________ }{\rtlch\fcs1 \af40\afs16 \ltrch\fcs0 
\f40\fs16\insrsid1342205\charrsid1342205 paid ( ) weekly ( ) every two weeks ( ) semi-monthly ( ) monthly ( ) yearly ( ) other _____________.
\par }{\rtlch\fcs1 \ai\af41\afs16 \ltrch\fcs0 \i\f41\fs16\insrsid1342205\charrsid1342205 (Net income is your total income including salary, wages, bonuses, commissions, allowances, overtime, tips and similar payments, }{\rtlch\fcs1 \ab\ai\af42\afs16 
\ltrch\fcs0 \b\i\f42\fs16\insrsid1342205\charrsid1342205 minus }{\rtlch\fcs1 \ai\af41\afs16 \ltrch\fcs0 \i\f41\fs16\insrsid1342205\charrsid1342205 deductions required by law and other court-ordered payments such as child support.)
\par 
\par }{\rtlch\fcs1 \af40\afs16 \ltrch\fcs0 \f40\fs16\insrsid1342205\charrsid1342205 3. }{\rtlch\fcs1 \ab\af39\afs16 \ltrch\fcs0 \b\f39\fs16\insrsid1342205\charrsid1342205 I have other income }{\rtlch\fcs1 \af40\afs16 \ltrch\fcs0 
\f40\fs16\insrsid1342205\charrsid1342205 paid ( ) weekly ( ) every two weeks  ( ) semi-monthly ( ) monthly ( ) yearly}{\rtlch\fcs1 \ab\af39\afs16 \ltrch\fcs0 \b\f39\fs16\insrsid1342205\charrsid1342205  }{\rtlch\fcs1 \af40\afs16 \ltrch\fcs0 
\f40\fs16\insrsid1342205\charrsid1342205 ( ) other _____________.}{\rtlch\fcs1 \ab\af39\afs16 \ltrch\fcs0 \b\f39\fs16\insrsid1342205\charrsid1342205 
\par }{\rtlch\fcs1 \ai\af41\afs16 \ltrch\fcs0 \i\f41\fs16\insrsid1342205\charrsid1342205 (Circle \'93Yes\'94 and fill in the amount if you have this kind of income, otherwise circle \'93No\'94)
\par }{\rtlch\fcs1 \af40\afs16 \ltrch\fcs0 \f40\fs16\insrsid1342205\charrsid1342205 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\tldot\tx2880\tlul\tx4320\tx5040\tldot\tx8640\tlul\tx10080\wrapdefault\faauto\rin0\lin0\itap0\pararsid1342205 {\rtlch\fcs1 \af40\afs16 \ltrch\fcs0 \f40\fs16\insrsid1342205\charrsid1342205 Second Job\tab Yes $\tab No
\tab Veterans\rquote  benefits\tab Yes $\tab No
\par Social Security benefits                                                                \tab Workers compensation\tab Yes $\tab No
\par }\pard \ltrpar\ql \fi720\li0\ri0\widctlpar\tldot\tx2880\tlul\tx4320\tx5040\tldot\tx8640\tlul\tx10080\wrapdefault\faauto\rin0\lin0\itap0\pararsid1342205 {\rtlch\fcs1 \af40\afs16 \ltrch\fcs0 \f40\fs16\insrsid1342205\charrsid1342205 For you\tab Yes $\tab No
\tab Income from absent family members\tab Yes $\tab No
\par For child(ren)\tab Yes $\tab No\tab Stocks/bonds\tab Yes $\tab No
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\tldot\tx2880\tlul\tx4320\tx5040\tldot\tx8640\tlul\tx10080\wrapdefault\faauto\rin0\lin0\itap0\pararsid1342205 {\rtlch\fcs1 \af40\afs16 \ltrch\fcs0 \f40\fs16\insrsid1342205\charrsid1342205 Unemployment compensation\tab 
Yes $\tab No \tab Rental income\tab Yes $\tab No
\par Union payments\tab Yes $\tab No\tab Dividends or interest\tab Yes $\tab No
\par Retirement/pensions\tab Yes $\tab No\tab Other kinds of income not on the list\tab Yes $\tab No
\par Trusts\tab Yes $\tab No \tab Gifts\tab Yes $\tab No
\par 
\par I understand that I will be required to make payments for fees and costs to the clerk in accordance with \'a757.082(5), Florida Statutes, as provided by law, }{\rtlch\fcs1 \af40\afs16 \ltrch\fcs0 \f40\fs16\ulw\insrsid1342205\charrsid1342205 
although I may agree to pay more if I choose to do so.
\par }{\rtlch\fcs1 \ab\af39\afs16 \ltrch\fcs0 \b\f39\fs16\insrsid1342205\charrsid1342205 
\par 4. I have other assets: }{\rtlch\fcs1 \ai\af41\afs16 \ltrch\fcs0 \i\f41\fs16\insrsid1342205\charrsid1342205 (Circle \'93yes\'94 and fill in the value of the property, otherwise circle \'93No\'94)
\par }{\rtlch\fcs1 \af40\afs16 \ltrch\fcs0 \f40\fs16\insrsid1342205\charrsid1342205 Cash\tab Yes $\tab No\tab Savings account\tab Yes $\tab No 
\par Bank account(s)\tab Yes $\tab No \tab Stocks/bonds\tab Yes $\tab No
\par Certificates of deposit or                                                               \tab Homestead Real Property*\tab Yes $\tab No
\par money market accounts\tab Yes $\tab No \tab Motor Vehicle*\tab Yes $\tab No
\par Boats*\tab Yes $\tab No\tab Non-homestead real property/real estate*\tab Yes $\tab No
\par 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0\pararsid1342205 {\rtlch\fcs1 \af40\afs16 \ltrch\fcs0 \f40\fs16\insrsid1342205\charrsid1342205 *show loans on these assets in paragraph 5
\par 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\outlinelevel0\rin0\lin0\itap0\pararsid1342205 {\rtlch\fcs1 \af40\afs16 \ltrch\fcs0 \f40\fs16\insrsid1342205\charrsid1342205 
Check one: I ( ) DO ( ) DO NOT expect to receive more assets in the near future.  The asset is_____________________________.
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0\pararsid1342205 {\rtlch\fcs1 \af40\afs16 \ltrch\fcs0 \f40\fs16\insrsid1342205\charrsid1342205 
\par 5. }{\rtlch\fcs1 \ab\af39\afs16 \ltrch\fcs0 \b\f39\fs16\insrsid1342205\charrsid1342205 I have total liabilities and debts of $________ }{\rtlch\fcs1 \af40\afs16 \ltrch\fcs0 \f40\fs16\insrsid1342205\charrsid1342205 
as follows:  Motor Vehicle $__________, Home $__________, Other Real Property $__________, Child Support paid direct  $__________, Credit Cards $__________, Medical Bills $__________, Cost of medicines (monthly) $______________, 
\par Other $__________.
\par 
\par 6. }{\rtlch\fcs1 \ab\af39\afs16 \ltrch\fcs0 \b\f39\fs16\insrsid1342205\charrsid1342205 I have a private lawyer in this case}{\rtlch\fcs1 \af40\afs16 \ltrch\fcs0 \f40\fs16\insrsid1342205\charrsid1342205 \'85\'85\'85\'85 Yes No}{\rtlch\fcs1 \af40\afs16 
\ltrch\fcs0 \f40\fs16\cf1\insrsid1342205\charrsid1342205 
\par }{\rtlch\fcs1 \af43\afs16 \ltrch\fcs0 \f43\fs16\insrsid1342205\charrsid1342205 
\par A person who knowingly provides false information to the clerk or the court in seeking a determination of indigent status under s. 57.082, F.S. commits a misdemeanor}{\rtlch\fcs1 \af43\afs16 \ltrch\fcs0 \f43\fs16\insrsid5063431  }{\rtlch\fcs1 \af43\afs16 
\ltrch\fcs0 \f43\fs16\insrsid1342205\charrsid1342205 of the first degree, punishable as provided in s.775.082, F.S. or s. 775.083, F.S. }{\rtlch\fcs1 \ab\af44\afs16 \ltrch\fcs0 \b\f44\fs16\insrsid1342205\charrsid1342205 I attest that th
e information I have provided on this application is true and}{\rtlch\fcs1 \ab\af44\afs16 \ltrch\fcs0 \b\f44\fs16\insrsid5063431  }{\rtlch\fcs1 \ab\af44\afs16 \ltrch\fcs0 \b\f44\fs16\insrsid1342205\charrsid1342205 accurate to the best of my knowledge.

\par }{\rtlch\fcs1 \af43\afs18 \ltrch\fcs0 \f43\fs18\insrsid1342205\charrsid1342205 
\par }\pard \ltrpar\ql \fi-5760\li5760\ri0\widctlpar\wrapdefault\faauto\rin0\lin5760\itap0\pararsid1342205 {\rtlch\fcs1 \af43\afs18 \ltrch\fcs0 \f43\fs18\insrsid1342205\charrsid1342205 Signed this _________ day of _______________, 20____.\tab 
____________________________________ 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0\pararsid1342205 {\rtlch\fcs1 \af43\afs18 \ltrch\fcs0 \f43\fs18\insrsid1342205\charrsid1342205 ___________\tab \tab ________________________\tab \tab Signature of Applicant f
or Indigent Status
\par Date of Birth \tab \tab }{\rtlch\fcs1 \af43\afs18 \ltrch\fcs0 \f43\fs18\cf1\insrsid1342205\charrsid1342205 Driver\rquote s}{\rtlch\fcs1 \af43\afs18 \ltrch\fcs0 \f43\fs18\cf17\insrsid1342205\charrsid1342205  }{\rtlch\fcs1 \af43\afs18 \ltrch\fcs0 
\f43\fs18\insrsid1342205\charrsid1342205 License or ID Number\tab \tab Print Full Legal Name }{\rtlch\fcs1 \af43\afs18 \ltrch\fcs0 \f43\fs18\insrsid1342205 _______}{\rtlch\fcs1 \af43\afs18 \ltrch\fcs0 \f43\fs18\insrsid1342205\charrsid1342205 
______________
\par }{\rtlch\fcs1 \af43\afs18 \ltrch\fcs0 \f43\fs18\insrsid1342205 \tab \tab \tab \tab \tab }{\rtlch\fcs1 \af43\afs18 \ltrch\fcs0 \f43\fs18\insrsid1342205\charrsid1342205 \tab }{\rtlch\fcs1 \af43\afs18 \ltrch\fcs0 \f43\fs18\insrsid1342205 \tab \tab }{
\rtlch\fcs1 \af43\afs18 \ltrch\fcs0 \f43\fs18\insrsid1342205\charrsid1342205 Phone Number: __________________________
\par _______________________________________\tab }{\rtlch\fcs1 \af43\afs18 \ltrch\fcs0 \f43\fs18\insrsid1342205 
\par }{\rtlch\fcs1 \af43\afs18 \ltrch\fcs0 \f43\fs18\insrsid1342205\charrsid1342205 Address, P O Address, Street, City, State, Zip Code\tab \tab \tab 
\par }{\rtlch\fcs1 \ab\af44\afs18 \ltrch\fcs0 \b\f44\fs18\insrsid1342205\charrsid1342205 
\par 
\par }\pard \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\faauto\outlinelevel0\rin0\lin0\itap0\pararsid1342205 {\rtlch\fcs1 \ab\af44\afs18 \ltrch\fcs0 \b\f44\fs18\insrsid14838619 
\par }{\rtlch\fcs1 \ab\af44\afs18 \ltrch\fcs0 \b\f44\fs18\insrsid1342205\charrsid1342205 CLERK\rquote S DETERMINATION
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\faauto\rin0\lin0\itap0\pararsid1342205 {\rtlch\fcs1 \af43\afs18 \ltrch\fcs0 \f43\fs18\insrsid1342205\charrsid1342205 
Based on the information in this Application, I have determined the applicant to be ( ) Indigent ( ) Not Indigent, according to s. 57.082, F.S.
\par Dated this _________ day of ______________, 20 ____.\tab \tab \tab 
\par }\pard \ltrpar\ql \fi720\li4320\ri0\widctlpar\wrapdefault\faauto\rin0\lin4320\itap0\pararsid1342205 {\rtlch\fcs1 \af43\afs18 \ltrch\fcs0 \f43\fs18\insrsid1342205\charrsid1342205 Clerk of the Circuit Court by }{\rtlch\fcs1 \af43\afs18 \ltrch\fcs0 
\f43\fs18\ul\insrsid1342205\charrsid1342205 \tab \tab \tab \tab 
\par }{\rtlch\fcs1 \af43\afs18 \ltrch\fcs0 \f43\fs18\insrsid1342205\charrsid1342205 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\tx3600\wrapdefault\faauto\rin0\lin0\itap0\pararsid1342205 {\rtlch\fcs1 \af43\afs18 \ltrch\fcs0 \f43\fs18\insrsid1342205\charrsid1342205 This form was completed with the assistance of:\tab 
__________________________________________________
\par }\pard \ltrpar\ql \li3600\ri0\widctlpar\wrapdefault\faauto\rin0\lin3600\itap0\pararsid1342205 {\rtlch\fcs1 \af43\afs18 \ltrch\fcs0 \f43\fs18\insrsid1342205\charrsid1342205 Clerk/Deputy Clerk/Other authorized person.}{\rtlch\fcs1 \af45\afs20 \ltrch\fcs0 
\f45\fs20\insrsid1342205\charrsid1342205 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid1342205 {\rtlch\fcs1 \af0\afs16 \ltrch\fcs0 \b\fs16\insrsid1342205\charrsid1342205 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid1342205 {\rtlch\fcs1 \af0\afs16 \ltrch\fcs0 \b\fs16\insrsid1342205\charrsid1342205 
APPLICANTS FOUND NOT TO BE INDIGENT MAY SEEK REVIEW BY A JUDGE BY ASKING FOR A HEARING TIME.
\par }{\rtlch\fcs1 \af0\afs16 \ltrch\fcs0 \fs16\insrsid1342205\charrsid1342205 THERE IS NO FEE FOR THIS REVIEW.
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid1342205 {\rtlch\fcs1 \af0\afs16 \ltrch\fcs0 \fs16\insrsid1342205\charrsid1342205 Sign here if you want the judge to review the clerk\rquote 
s decision __________________________________________}{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \fs24\insrsid1342205\charrsid1342205 
\par }\pard \ltrpar\ql \li0\ri0\sl480\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid1342205 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid1342205 
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