Page 1 of 2 171 - 430 ( Rev. 12 /1 7 ) IN THE CIRCUIT COURT OF THE NINETEENTH JUDICIAL CIRCUIT LAKE COUNTY, ILLINOIS ) ) ) Plaintiff(s) ) vs. ) ) ) ) Gen No . Defendant(s) ) INCOME AND ASSET FORM To Judgment Deb tor: Please complete this form and bring it with you to the hear ing referenced in the enclosed C itation N otice. 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 kno wledge. 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 Job: I earn: $ per If self - employed, list your business name and address: Income from sel f - employment is: $ per I have the following benefits with my employer: I do not have a job, but I support myself through: Government Assistance $ per month Unemployment $ per month Social Security $ per month SSI $ per month Pension $ pe r month Other $ per month 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: I have a beneficial interest in a land trust. The name and address of the trustee is . American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 171 - 430 ( Rev. 12 /1 7 ) The beneficial interest is listed in my name and 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 DVD Player Television Stove Microwave Work tools Business Equipment F arm 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 Prepared by: Name: Pro Se Address: City: State: Phone: Zip Code: ARDC #: E - mail address: American LegalNet, Inc. www.FormsWorkFlow.com