Application for Civil Indigent Status (FL 57.082) fl.fee.waiver qweb-pdf activeblue_familylaw.report_fee_waiver activeblue_familylaw/report/report_fee_waiver 'Fee Waiver Application - ' + object.case_id.name report

Full Legal Name:		Date of Birth:
Address:	, , FL _____________________________________________
Phone:		Email:
Role in Case:	[ ] Petitioner [ ] Respondent

Number of persons in household:
Monthly Gross Income (all sources):	$
Annual Gross Income (× 12):	$
Federal Poverty Level (200%) for household of :	$/year