Illinois > Statewide > Office Of The State Appellate Defender > Petitions And Notices (Expunge And Seal)
Application And Affidavit To Sue As An Indigent Person - Illinois
| Application And Affidavit To Sue As An Indigent Person Form. This is a Illinois form and can be used in Petitions And Notices (Expunge And Seal) Office Of The State Appellate Defender Statewide . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
IN THE CIRCUIT COURT OF THE ___________________JUDICIAL CIRCUIT _____________________________COUNTY, ILLINOIS [ ] THE PEOPLE OF THE STATE OF ILLINOIS ) or ) [ ] A MUNICIPAL CORPORATION, ) ) vs. ) ) _________________________________ ) Defendant/Petitioner. ) CASE NO. ________________ APPLICATION AND AFFIDAVIT TO SUE AS AN INDIGENT PERSON COMES NOW, _____________________________, Defendant/Petitioner herein, age _________, pursuant to 735 ILCS 5/5-105, and Petitions this Court for leave to sue as an indigent person. In support of this Petition, Defendant/Petitioner states as follows: Employer: ____________________________________________________ (Name of Employer) (Street Address) (City) OR I am unemployed as of ______________________________. (Date of unemployment) (Name of Employer) Last employer:______________________________________________________ ______________________________________________________ (Street Address) I began receiving unemployment compensation on _________________ in the amount of (Date) $______________________ per month. 2.` My spouse is employed as a(n): _______________ Annual gross salary $________ ` ` 1. I am employed as a(n): ____________________ Annual gross salary $__________ _____________________________________________________ _____________________________________________________ (State) (ZIP) ______________________________________________________ (City) (State) (ZIP) 1 American LegalNet, Inc. www.USCourtForms.com Spouse's employer:_____________________________________________________ (Name of Employer) _____________________________________________________ (Street Address) ______________________________________________________ (City) (State) (ZIP) OR My spouse is unemployed as of ______________________________. (Date of unemployment) My spouse began receiving unemployment compensation on ______________ in the amount of (Date) $______________________ per month. 3. My other sources of income are: SSI Public Aid Child Support Family Assistance Foster Care Aid to the Aged, Blind and Disabled Temporary Assistance for Needy Families General Assistance State Transitional Assistance State Children and Family Assistance Other:_____________________________________________________________ Totaling ______________________________________ $ per month 4. My available income is 125% or less of the current poverty level established by the State Department of Health and Human Services. 5. The nature and value of property I own includes: Real Estate (Describe property, specify address, present value and mortgage and liens outstanding)___________________________________________________________________ Cash, Bank accounts, etc.$__________________ Clothing and jewelry $________________ Furniture appliances, household goods $___________________________________________ AutomobileModel________________ Year______________ Value $___________________ 6. The names and ages of persons dependent on the applicant for support are: __________________________/___________ __________________________/___________ (Name) (Age) (Name (Age) __________________________/___________ __________________________/___________ (Name) (Age) (Name (Age) __________________________/___________ __________________________/___________ (Name) (Age) (Name (Age) 2 ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` Last employer:______________________________________________________ (Name of Employer) ______________________________________________________ (Street Address) ______________________________________________________ (City) (State) (ZIP) American LegalNet, Inc. www.USCourtForms.com 7. I am paying child support in the amount of $___________________per ________________. 8. I am paying spousal support in the amount of $_____________________ per ____________. 9. My monthly living expenses (not including payment of debts and child support) are $______. 10. I am unable to pay the costs of this case and to do so would cause a substantial hardship to me and my family. WHEREFORE, the Defendant/Petitioner prays that this Court grant Defendant/Petitioner leave to sue as an indigent person. 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 Subscribed and sworn to before me this _____ day of ___________________, 20____. __________________________________________________________________________ Prepared by: Name______________________________ Address____________________________ City/State/Zip_______________________ ` 11. ` I am eligible to receive civil legal services as defined in 735 ILCS 5/5-1015.5. _____________________________________ Defendant/Petitioner _______________________________________ Notary/Clerk Atty No.________________________ Attorney for _____________________ Telephone_______________________ 3 American LegalNet, Inc. www.USCourtForms.com
|
|||||||
