Indigency Application

This form is to determine if you qualify for indigency. Please complete all portions of this form and submit. All applicants for payment extension must be interviewed; terms for payment will be established; all questions about the payment of fine and costs will be answered at that time. You will be required to submit supporting documents at the time of the interview.

  1. Apply Online

Indigency Application

Steps

  1. 1. Instructions
  2. 2. Questionnaire
  3. 3. Personal Information
  4. 4. Employment and Income
  5. 5. Personal Assets
  6. 6. Monthly Expenses
  7. 7. Acknowledgements

  • Instructions

    2. This form is to determine if you qualify for indigency. Please complete all portions of this form and submit. All applicants for payment extension must be interviewed; terms for payment will be established; all questions about the payment of fine and costs will be answered at that time. You will be required to submit supporting documents at the time of the interview.

    4. Supporting Documents
      • Income Tax return for year immediately preceding your court date. 
      • Banking Statements for the previous three months
      • Proof of unemployment disposition and benefit
      • Proof of Social Security Income for any household member
      • Proof of child support or nonpayment of child support
      • Proof of utility expenses including electric, gas, water, telephone, garbage, cable, internet, etc. 
      • Proof of housing expense including mortgage payment or rental agreement. 
      • Proof of vehicle lease, ownership, or other transportation expenses. 
      • Proof of medical expenses 
      • Proof of government financial supplements and assistance, including food, housing and Medicare subsides. 
      • Proof of private grants or donations