subject_line
QUESTIONNAIRE FOR FILING FEE WAIVER
Type of case
*
Divorce With Out Minor Child
Divorce With Minor Child
Adoption - Relative
Adoption - Step-Parent
Adoption - Adult
Temporary Custody
Paternity
Name Change
Summary of Administration
Other
Full Legal Name
(
First, Middle, Last
)
*
Email Address
*
Your Address
*
Phone Number
*
Date of Birth
*
Driver License or ID Number
*
Issuing State (License/ID)
*
Are you married?
*
Yes
No
Does your spouse work?
*
Yes
No
Annual Spouse Income?
*
How many dependents do you have? (Include only those persons you list on your U.S. Income Tax Return).
*
🛈
0
1
2
3
4
5
6
7
8
9
My Employment/Job Situation is:
*
🛈
I am unemployed. I do not have a job.
I work full time.
I work part time.
I Get Paid...
*
Weekly (Once a Week)
Bi-Weekly (Every Two weeks)
Semi-Monthly (Twice a Month)
Monthly (Once Every Month)
Yearly (Once a Year)
My take-home (NET) income each pay period is:
*
🛈
OTHER TYPES OF MONTHLY INCOME - IF YOU ANSWER "YES" TO ANY QUESTION, YOU MUCH INDICATE THE MONTHLY AMOUNT YOU RECEIVE
Do You Have a Second Job?
*
No
Yes
Monthly Net Income from 2nd Job
*
🛈
Do you receive Social Security benefits?
*
No
Yes
MONTHLY Social Security Benefit Amount:
*
Does your child(ren) receive Social Security Benefits?
*
No
Yes
Child(ren) Social Security Benefit - MONTHLY
*
Do you receive any Unemployment Compensation?
*
No
Yes
Monthly Amount (UC)
*
🛈
Do you receive payments from any Unions?
*
No
Yes
Monthly Amount (UP)
*
🛈
Do you receive any income from a Pension or Retirement Plan?
*
No
Yes
Monthly Amount (RP)
*
🛈
Do you receive any income from Trusts or Gifts?
*
No
Yes
Monthly Amount (TG)
*
🛈
Do you receive any Veteran's Benefits income?
*
No
Yes
Monthly Amount (VB)
*
🛈
Do you receive Worker's Compensation payments?
*
No
Yes
Monthly Amount (WC)
*
🛈
Do you receive any income from absent family members?
*
No
Yes
Monthly Amount (AF)
*
🛈
Do you receive any income from Stocks or Bonds?
*
No
Yes
Monthly Amount (SB)
*
🛈
Do you receive any rental income?
*
No
Yes
Monthly Amount (RI)
*
🛈
Do you receive income from dividends or interest?
*
No
Yes
Monthly Amount (DI)
*
🛈
Other types of income not mentioned?
*
No
Yes
Monthly Amount (OI)
*
🛈
Total Debt?
*
Describe the Source of this Other Income
*
🛈
INFORMATION ABOUT YOUR ASSETS
How much cash do you have that's NOT in the bank? (Money in your pocket, wallet, purse, at home, etc.?)
*
Do You Have a Checking Account(s)?
*
Yes
No
How Much Money is in Your Checking Account(s)?
*
🛈
Do you have a Savings Account(s)?
*
Yes
No
How Much Money is in your Savings Account(s)?
*
🛈
Do you have Certificates of Deposit or Money Market accounts?
*
Yes
No
How much money do you have in Certificates of Deposit or Money Market accounts?
*
🛈
Do your own Stocks or Bonds?
*
Yes
No
What is the Current Value of your Stocks and/or Bonds?
*
How many motor vehicles do you own?
(Cars, Trucks, Motorcycles, SUV's)
*
0
1
2
3
4
5
If you sold
ALL
of your motor vehicles, how much money could you get for them?
*
🛈
How Many Boats do You Own?
*
0
1
2
3
4
5
If you sold
ALL
of your boats, how much money could you get for them?
*
🛈
Do you own
homestead
real property?
*
Yes
No
What is the current value of your homesteaded property?
*
Do you own
Non-Homestead
real property/real estate?
*
Yes
No
What is the current value of your non-homestead property/real estate?
*
INFORMATION ABOUT YOUR DEBTS
How much do you owe on motor vehicle (car/truck/motorcycle/SUV/ loans?
*
How much do you owe on your boat/jetski loan(s)?
*
How much do you owe on your home mortgage?
*
How much do you owe on
other
real estate property?
*
How much money do you pay in child support each month?
*
How much money do you owe on your credit cards?
*
How much money do you owe on medical bills?
*
How much money do you owe in student loans?
*
How much money a month do you spend for medications that your insurance doesn't cover?
*
Do you have other debts that aren't listed? If so, enter amount and explain.
*
Do you have a private lawyer in this case?
*
No
Yes
A person who knowingly provides false information to the clerk or the court in seeking a determiniation of indigent status under F.S. 57.082 commits a misdemeanor of the first degree, punishable as provided in FS 775.082 or FS 775.083.
Do you attest that the information you have provided on this questionnaire is true and accurate to the best of your knowledge?
*
YES