IN THE CIRCUIT COURT OF THE TENTH JUDICIAL CIRCUIT

IN AND FOR HARDEE, HIGHLANDS AND POLK COUNTIES, FLORIDA

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Affiant

After careful consideration of the Affidavit of Insolvency executed under oath by the Affiant,

I HEREBY ADJUDGE that __________________________________ is/is not (circle one) insolvent within the intent and meaning of Section 57.081 of the Florida Statutes and

THEREFORE is/is not (circle one) entitled to the services of the Court, Sheriff and Clerk of the Court in the County of ______________________________ without initial charge. If, however, costs are recovered, they shall be paid to the Clerk.

DONE AND ORDERED on this ________ day of ___________________________, 2000.

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Judge

Copy: Above Affiant