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Application And Affidavit To Sue Or Defend As An Indigent Person CCG N689 - Illinois
| Application And Affidavit To Sue Or Defend As An Indigent Person Form. This is a Illinois form and can be used in General Cook Local County . |
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Print Form Application and Affidavit to Sue or Defend as an Indigent Person IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Clear Form (11/8/07) CCG N689A _________________________________________________________ Plaintiff/Petitioner v. _________________________________________________________ Defendant/Respondent } No. ___________________________________ ______________________________ Calendar APPLICATION AND AFFIDAVIT TO SUE OR DEFEND AS AN INDIGENT PERSON 1. My Name is ______________________________________________ and I am _________________ years old. I live at (do not provide a P.O. Box #) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ My phone number is (________) _______ - ____________. 2. I am filing this application for (check one): Myself A minor whose name is ______________________________________________ and who is _________ years old. An incompetent adult whose name is ________________________________________ and who is _________ years old. Other (Please explain) _______________________________________________________________________________________________________. 3. I have retained an attorney to represent me in this matter (check one): Yes No The attorney's name is: ________________________________. 4. Assets: I own (check all that apply): Real Estate, which is located at ___________________________________________________________________________________________. I estimate the value of the property to be $ _________________. Automobile or other vehicle - Make ______________________________________ Year ____________ Jewelry, estimated value $ _________________ Cash and/or bank accounts in the amount of $ _________________ Any other property value, estimated value $ _________________ 5. Fill out this section (and skip section #6, below) if you are currently employed: I am employed as a(n) ___________________________________ and the name of my employer is ______________________________________________. My employer can be reached by telephone at (_________) _____________________. During the last year I earned $ _________________ (before taxes). I expect to earn $ _________________ (before taxes) in the upcoming year. My other sources of income are (check all that apply): SSI Estimated Value $ ________________ Public Aid Food Stamps or Illinois LINK Card Family Assistance Pension Social Security Other (Please specify) _______________ Child Support or Spousal Support (alimony) ___________________________________________. Disability The total income from these sources is $ _________________ per month. 6. Fill out this section if you are currently not working: I have been unemployed or retired since _______/ _______/ _______. My last job was as a(n) ________________________________ and my former employer was ______________________________________________. My sources of income are (check all that apply): Unemployment SSI Public Aid Food Stamps or Illinois LINK Card Family Assistance Child Support or Spousal Support (alimony) Disability Pension Social Security Other (Please specify) ___________________________________________________________. The total income from these sources is $ _________________ per month. Petitioner's Copy of Application and Affidavit to Sue or Defend as an Indigent Person 735 ILCS 5/5-105 (Rev. 11/8/07) CCG N689 A INFORMATION SHEET FOR LEAVE TO SUE OR DEFEND AS AN INDIGENT PERSON (a) As used in this section: (1) "Fees, costs, and charges" means payments imposed on a party in connection with the prosecution or defense of a civil action, including, but not limited to: filing fees; appearances fees; fees for service of process and other papers served either within or outside this State, including service by publication pursuant to Section 2-206 of this Code and publication of necessary legal notices; motion fees; jury demand fees; charges for participation in, or attendance at, any mandatory process or procedure including, but not limited to, conciliation, mediation, arbitration, counseling, evaluation, "Children First", "Focus on Children" or similar programs; fees for supplementary proceedings; charges for translation services; guardian ad litem fees; charges for certified copies of court documents; and all other processes and procedures deemed by the court to be necessary to commence, prosecute, defend, or enforce relief in a civil action. 2) "Indigent person" means any person who meets one or more of the following criteria: (i) He or she is receiving assistance under one or more of the following public benefits programs: Supplemental Security Income (SSI), Aid to the Aged, Blind and Disabled (AABD), Temporary Assistance for Needy Families (TANF), Food Stamps, General Assistance, State Transitional Assistance, or State Children and Family Assistance. (ii) His or her available income is 125% or less of the current poverty level as established by the United States Department of Health and Human Services, unless the applicant's assets that are not exempt under Part 9 or 10 of Article XII of this Code are of nature and value that the court determines that the applicant is able to pay the fees, costs and charges. (iii) He or she is, in the discretion of the court, unable to proceed in an action without payment of fees, costs, and charges and whose payment of those fees, costs, and charges would result in substantial hardship to the person or his or her family. (iv) He or she is an indigent person pursuant to Section 5-105.5 of this Code. [This states that "indigent person" means a person whose income is 125% or less of the current official federal poverty guidelines or who is otherwise eligible to receive civil legal services under the Legal Services Corporation Act of 1974. (42 U.S.C.A. Sec. 2996 et. seq.)] (b) On the application of any person, before or after the commencement of an action, a court, on finding that the applicant is an indigent person, shall grant the applicant leave to sue or defend the action without payment of the fees, costs and charges of the action. (c) An application for leave to sue or defend an action as an indigent person shall be in writing and supported by the affidavit of the applicant or, if the applicant is a minor or an incompetent adult, by the affidavit of another person having knowledge of the facts. The contents of the affidavit shall be established by Supreme Cour
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