3116 (Rev. 3/7/01) CCM 0128 ANSWER TO CITATION PROCEEDING Case: ________________________________ vs. ________________________________________ No.: _________________________________ In answer to the citation and supplemental proceedings served upon ____________________________________________ he/she answers under oath as follows: Name: ____________________________________________________________ Home Phone # _____________________________________ Home Address _____________________________________________________________________________________________________________ Driver's License __________________________________________________ Date of Birth: ____________________________ I am Do you have a job? q No q Yes q Married Social Security # _____________________________________ q Single q Divorced I have _______ dependents Company's name I work for: ______________________________________________ I do not have a job, but I support Their address: ___________________________________________________________ myself through: Job:_____________________________________________ Public Aid $ _______________ per month I earn $_______________ per _______________ Unemployment $ ___________ per month If self-employed, check here q and list business name and address: Social Security $ ___________ per month ________________________________________________________________________ SSI $ ______________________ per month Income from self-employment $ ______________________ per year Pension $ ___________________ per month I have the following benefits with my employer: _____________________________ Other $ ____________________ per month ___________________________________________________________________________ q I do not own any real estate. q I own property at ____________________________________________________________, with ____________________________________. q 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 _____________________________________________________________________________________________. q There is a mortgage on my property. The mortgage company's name and address are: ____________________________________ _____________________________________________________________________________________________________________________. q An assignment of beneficial interest in the land trust was signed to secure a loan from ____________________________________ _____________________________________________________________________________________________________________________. q I have no money in bank accounts, savings & loans, credit unions, money markets, or mutual funds. q I have the following accounts: q checking account at ________________________________________________________ account balance $____________________ q savings account at _________________________________________________________ account balance $____________________ q money market or certificate of deposit at ________________________________________________________________________________ q safe deposit box at ___________________________________________________________________________________________________ q I own: q a car __________________________________________________________ VIN: _______________________________________ (make/model) q jewelry: (specify) _________________________________________________________________________________________ q 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 Print This Form For your protection and privacy, please press the Clear This Form button after you have printed the form. Clear This Form