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Affidavit Of Assets And Liabilities CCJP 0041 - Illinois
| Affidavit Of Assets And Liabilities Form. This is a Illinois form and can be used in Juvenile Protection Cook Local County . |
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Af¿davit of Assets and Liabilities Print Form Clear Form (12/07/10) CCJP 0041 IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS DEPARTMENT OF JUVENILE JUSTICE AND CHILD PROTECTION CHILD PROTECTION DIVISION IN THE INTEREST OF ______________________________________________________ A Minor Petition No. ___________________________________ AFFIDAVIT OF ASSETS AND LIABILITIES I,_____________________________________________________ (Parent) of the minor respondent in this case, on oath state that I am ¿nancially unable to hire a lawyer and I am requesting to be represented by the Public Defender of Cook County. Address ___________________________________________________________________________________________________ City: ____________________________ State: ________________ Zip Code: _______________ I am: Married Single Divorced Separated Telephone:_________________________ Number of children I support by court order _________________ MOTHER Employed? Yes No FATHER Employed? Yes No If so, where? _____________________________________________ Position _________________________________________________ Salary ___________________________________________________ weekly bi-weekly monthly other__________________ Any other income i.e.: child support, Social Security Disability, etc.? ____________________________________________________ ________________________________________________________ Do you own a car? Yes No If so, what model/make/year _______________________________ Do you own a home? Yes No If so, how long? __________________________________________ Do you have a savings account or any other investments? Yes No Total value ______________________________________________ List major debts: creditors and amounts. Monthly payments: _______________________________________ ________________________________________________________ ________________________________________________________ If so, where? ____________________________________________ Position ________________________________________________ Salary _________________________________________________ weekly bi-weekly monthly other________________ Any other income i.e.: child support, Social Security Disability, etc.? ___________________________________________________ ________________________________________________________ Do you own a car? Yes No If so, what model/make/year _______________________________ Do you own a home? Yes No If so, how long? __________________________________________ Do you have a savings account or any other investments? Yes No Total value ______________________________________________ List major debts: creditors and amounts. Monthly payments: ______________________________________ ________________________________________________________ ________________________________________________________ TOTAL DEBTS/MORTGAGE/CAR PAYEMENT/PERSONAL DEBTS ____________________________________________________ DATED: _______________________________, ___________ ___________________________________________________ Parent or Guardian The undersigned certi¿es that the statements set forth in this instrument are true and correct and certi¿es under penalties of perjury as provided by law pursuant to 753 ILCS 5/1-109. __________________________________________________ Respondent-Parent DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS
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