(Rev. 1/2/01) CCG 0041 A IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS PEOPLE OF THE STATE OF ILLINOIS v. ______________________________________________ } No. _____________________________ No. ______________________________ No. _____________________________ AFFIDAVIT OF ASSETS AND LIABILITIES I, _________________________________________ defendant in this case, on oath state that I am without adequate assets to retain counsel, and that I make the following statement in support of my request to be represented by courtappointed counsel. 1. Name ____________________________________________ Date of Birth _______________________ 2. Address _________________________________________ Phone _________________________ 3. Family: (a) Marital Status _______ (b) Number of Children _______ (c) Number of other Dependents ______ and relationship ______________________________________________________________________ _________________________________________________________________________________ 4. Name and address of employer _____________________________________________________________ Length of employment ___________________ Occupation ____________________________________ 5. Earnings and sources of income: (a) $ ______________________ per month from employment. (b) $ _______________________ per month from pension, trusts, annuity, welfare, Workers' Compensation, retirement or disability plan or any similar State, Federal, Local or private benefit plan. (c) $ _______________________ per month from rents, royalties, bonds, securities, or interest. (d) $ ________________________ per month from other sources enumerated herein _________________ ____________________________________________________________________________. (e) $ _______________________ per month from all sources. 6. Value of assets: (a) Home or other dwellings $ _____________________________________________________________ (b) Other real property $ _______________________ Where situated ___________________________ (c) Car $ ________________________ Make ________________________________ Year __________ (d) Other personal property (jewelry, household contents, furs, etc.) $ ____________________________ (e) Bank Accounts $ __________________________________________________________________ (f) Cash on hand $ ___________________________________________________________________ (g) Surrender value of life or annuity insurance policies $ _______________________________________ (h) Securities, trusts, bonds $ ____________________________________________________________ (i) Other assets $ _____________________________ Described herein ____________________________ (j) Total value of assets $ _________________________________________________________________ (OVER) DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS (Rev. 1/2/01) CCG 0041 B 7. Liabilities: (a) Mortgage on home $ _________________________ Monthly payment $ __________________________ (b) Amount owed on car $ ________________________________________________________________ (c) Personal debts $ _______________________ To whom owed _________________________________ (d) Other debts $ _________________________ To whom owed ________________________________ (e) Total liabilities and debts $ ___________________________________________________________ 8. If released on bail, specify amount of security $ ____________________________ and source or payment of security (defendant's funds, borrowed cash, etc.) ______________________________________________ ________________________________________________________________________________ ______________________________________ Defendant Subscribed and sworn to before me _________________________________, _______ _______________________________________ Deputy Clerk **************************************************************** ORDER It is ordered that the Public Defender is appointed as counsel to represent the defendant. Date: ______________________________ ENTER: ____________________________________ Judge Judge's No. Branch: ____________________________ 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