Answer to Citation Proceeding (1/04/16) CCM N128 ANSWER TO CITATION PROCEEDING Case: ___________________________________ v. _________________________________ No.: ___________________________ In answer to the citation and supplemental proceedings served upon _____________________________________________ , s/he answers under oath as follows: Name: _________________________________________________________ Home Phone No._____________________________ Home Address: _______________________________________________________________________________________________ Driver's License No.: _______________________________________ Social Security No.:_________________________________ Date of Birth: _____________________________________ I am Primary Email Address: married single divorced. I have _____ dependents. _____________________________________________________________________________________ Name of Company I work for: ________________________________________ Company's Address: ________________________________________________ Job: ________________________________ I earn $ _________ per _____________ If self-employed, check here and list business name and address: ________________________________________________________________ Income from self-employment $___________ per year I have the following benefits with my employer: ___________________________ ________________________________________________________________ Do you have a job? Yes No I do not have a job, but I support myself through: Public Aid $ _____________________per month Unemployment $ _________________per month Social Security $ __________________per month SSI $ __________________________per month Pension $ _______________________per month Other $ ________________________per month 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 _____________________________________ ______________________________________________________________________________________________________ . I have no money in bank accounts, savings & loans, credit unions, money markets, or mutual funds. I have the following accounts: checking account at ___________________________________________________________ account balance $__________ savings account at ____________________________________________________________ account balance $__________ money market or certificate of deposit at ____________________________________________________________________ safe deposit box at _____________________________________________________________________________________ I own: a car_____________________________________________________ VIN: ______________________________ jewelry: (specify) _______________________________________________________________________________ other property described as: _______________________________________________________________________ Stocks VCR Refrigerator Bonds Stove TV set Microwave Work Tools ________________________________________ Signature DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com