ANSWER TO CITATION PROCEEDING Case Name:______________________________________________________ Case No.:____________________ In answer to the Citation and supplemental proceedings served upon ______________________________________ he / she answers under oath as follows: Name:________________________________________________________ SSN_________________________ Home Address:__________________________________________________________________________________ Home Phone:________________________________________________ DL#:______________________________ Date of Birth:_________________ I am I have ______dependants. Employed?: Yes Single Married Divorced Widowed List names and ages._____________________________________________________ I do not have a job, but I support myself through: No If yes, are you self employed? Yes No Public Aid $_______________ per month Company Name and Address: Unemployment $_______________ per month __________________________________________________ Social Security $_______________ per month __________________________________________________ SSI $_______________ per month __________________________________________________ Pension $_______________ per month Work Phone:_______________________________________ Other $_____________________ per month Job Title:__________________________________________ (list source)______________________________ I earn $_______________ per _________________________ ________________________________________ I have no money in bank accounts, savings & loans, credit unions, money market or mutual funds I have the following accounts: at_________________________________________ with a balance of $____________ Checking Account Savings Account at_________________________________________ with a balance of $____________ Money Market at_________________________________________ with a balance of $____________ Certificate of Deposit at_________________________________________ with a balance of $____________ Safe Deposit Box at_________________________________________ containing___________________ I do not own any real estate. I own property at ___________________________________________________ with______________________ I have a beneficial interest in a land trust. The name and address of the trustee are: ______________________________________________________________________________________________ The beneficial interest is listed in my name and _____________________________________________________ There is a mortgage on my property. The mortgage company’s name and address are: ______________________________________________________________________________________________ An assignment of beneficial interest in the land trust was signed to secure a loan from: ______________________________________________________________________________________________ 171-351 06/05 American LegalNet, Inc. www.FormsWorkFlow.com I own: _____ a car(s) (make and model) ________________________________ VIN:_______________________ Lien holder: ____________________________________________________________________________________ (make and model) ________________________________ VIN ________________________ Lien holder: ____________________________________________________________________________________ jewelry: (description)____________________________________________________________________ ________________________________________________________________________________________ Stocks/Bonds (name/institution and value)___________________________________________________ ________________________________________________________________________________________ Income Tax Returns presented for tax years: _________________________________________________________ Any asset/property not noted above valued over $500.00: ______________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Money people owe debtor: From Whom: Amount: From Whom: Amount: Debtor’s Signature(s) _________________________________ __________________________________ _________________________________ ___________________________________ Print Name Print Name Dated: __________________________, 20_____ 171-351 06/05 American LegalNet, Inc. www.FormsWorkFlow.com