Illinois > Local County > Lake > Small Claims
Income And Asset Form 171-430 - Illinois
| Income And Asset Form Form. This is a Illinois form and can be used in Small Claims Lake Local County . |
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IN THE CIRCUIT COURT OF THE NINETEENTH JUDICIAL CIRCUIT LAKE COUNTY, ILLINOIS ) ) vs. ) Judgment Creditor, ) ) ) ) ) Judgment Debtor. ) Case. No. INCOME AND ASSET FORM To Judgment Debtor: Please complete this form and bring it with you to the hearing referenced in the enclosed Citation Notice. You should also bring to the hearing any documents you have to support the information you provide in this form, such as pay stubs and account statements. This information you provide will help the court determine whether you have any property or income that can be used to satisfy the judgment entered against you in this matter. The information you provide must be accurate to the best of your knowledge. If you fail to appear at this hearing, you could be held in contempt of court and possibly arrested. In answer to the citation and supplemental proceedings served upon the judgment debtor, he or she answers as follows: Name: ________________________________________ Home Phone Number: ________________________________ Home Address:_____________________________________________________________________________________ Date of Birth: ____________________ Marital Status: _______________________ I have _______ dependents. I. JOB Do you have a job? Yes No Company's name I work for: _____________________________________ Company's address: _____________________________________________________________________________ Job: ____________________________________________ I earn: $ ________ per __________ If self-employed, list your business name and address: __________________________________________________ ______________________________________________________________________________________________ Income from self-employment is: $ _______ per ________ I have the following benefits with my employer: ________________________________________________________ I do not have a job, but I support myself through: Government Assistance Social Security Pension II. REAL ESTATE Do you own any real estate? Yes No I own real estate at: _____________________________________________________ with names of other owner(s) ______________________________________________________________________________________________ Additional real estate I own: _______________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Page 1 of 2 171-430 (Rev. 08/12) American LegalNet, Inc. www.FormsWorkFlow.com $ _____ per month $ _____ per month $ _____ per month Unemployment $ _____ per month SSI Other $ _____ per month $ _____ per month I have a beneficial interest in a land trust. The name and address of the trustee is ____________________________ . The beneficial interest is listed in my name and ________________________________________________________ There is a mortgage on my real estate. State the mortgage company's name and address for each parcel of real estate owned: __________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ An assignment of beneficial interest in the land trust was signed to secure a loan from _________________________ ______________________________________________________________________________________________ ............ III. OTHER ASSETS I have the following accounts: Checking account at: ___________________________________________________ ; Account balance: $ _________ Savings account at: ____________________________________________________ ; Account balance: $ _________ Money market or Certificate of Deposit at: __________________________________ ; Account balance: $ _________ Safe deposit box at: ____________________________________________________ ; Other accounts: (please identify) ____________________________________________________________________ ______________________________________________________________________________________________ I own: A vehicle: (state year, make, model and VIN) __________________________________________________________ Jewelry (please specify) __________________________________________________________________________ Other property described as: Stocks/Bonds ______________________________________________________________________________ Personal computer _________________________ Television ________________________________ Microwave _______________________________ DVD Player _________________________________ Stove ______________________________________ Work tools __________________________________ Business Equipment _________________________________________________________________________ Farm Equipment ____________________________________________________________________________ Other property (please specify) ________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ VERIFICATION BY CERTIFICATION Under penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, the undersigned certifies that the statements set forth in this instrument are true and correct, except as to matters therein stated to be on information and belief, as to such matters the undersigned certifies as aforesaid he/she verily believes the same to be true. Date:______________, 20____ _______________________________________ Judgment Debtor Page 2 of 2 171-430 (Rev. 08/12) American LegalNet, Inc. www.FormsWorkFlow.com
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