Application To Sue As A Poor Person

STATE OF ILLINOIS IN THE CIRCUIT COURT OF THE ___________ JUDICIAL CIRCUIT __________________ COUNTY ) IN RE THE MATTER OF: ) _____Application granted ) _____Application denied _____________________ ) ) ) No. _______ ) ) __________________, 20__ ) ) ________________________ JUDGE APPLICATION TO SUE AS A POOR PERSON I, _____________________________________, on my own behalf, on oath stat e: 1. My current address is _________________________________________________ . 2. My occupation, source of income, amount of public benefits is _________ _______. 3. My other sources of income or support are _____________________________ ___. 4. My income for the preceding year was approximately ____________________ ____. 5. The sources and amounts of income I expect to receive in the future are : _____________________________________________________________________. 6. Person(s) who are dependent on me for support are: __________________ ______ _____________________________________________________________________ _____________________________________________________________________. American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 27. I own no real estate. The total value of all my personal property does not exceed $___________ in value and consists of clothing and furniture, and other household items, including a 20____, ____________ motor vehicle, valued at $______ ______. 8. I filed no applications for leave to sue or defend as a poor person duri ng the preceding year, and none were filed on my behalf. 9. I am unable to pay the costs of commencing and prosecuting this action. 10. I have a meritorious claim. WHEREFORE, Applicant prays the Court to permit her/him to commence and prosecute this action as a poor person under 735 ILCS 5/5-105 of the Cod e of Civil Procedure. ___________________________________ Plaintiff Under penalties as provided by law pursuant to Section 5/1-109 of the Code of Civil Procedure, the undersigned certifies that the statements s et forth in this instrument are true and correct, except as to matters therein stated to be on information and belief and as to such matters the undersigned certifies as aforesaid that he/she verily believes the same to be true. ___________________________________ Plaintiff American LegalNet, Inc. www.USCourtForms.com