Print Form Clear Form Af¿davit of Assets and Liabilities IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS PEOPLE OF THE STATE OF ILLINOIS v. (10/5/11) CCG N041 A No. ________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________ Defendant AFFIDAVIT OF ASSETS AND LIABILITIES I, the Defendant in this case, state that I am without adequate assets to retain counsel for the following reasons: Personal Information 1. Name ________________________________________________________________________________________________________________________________________________________________________________________________________ Date of Birth _________________________________________________________________ 2. Address _________________________________________ Telephone _________________________ 3. Family: (a) Marital Status ___________________________________________ (b) Number of Children __________________________ (c) Number of other Dependents _________________________ If other dependents, their relationship _______________________________________________________ 4. (Check which one is applicable) I am not employed I am employed If employed, name and address of employer __________________________________________________ Length of employment ___________________ Occupation ____________________________________ Amount earned from employment (¿ll in one): $______________ weekly monthly every 2 weeks My take-home pay is $ _________________ per pay period. Expenses or Liabilities: 5. (a) Monthly mortgage payment $______________________ or monthly rent $______________________ (b) Monthly car payment $_______________________________________________________________ (c) Monthly child support and/or alimony $__________________________________________________ (d) Monthly credit card payments $________________________________________________________ (e) Other $_________________________________________________________________________ (f) Total liabilities and debts $____________________________________________________________ 6. If released on bail, specify amount of security $____________________________ and source or payment of security (defendant's funds, borrowed cash, etc.) _________________________________________________ ______________________________________________________________________________________ Assets: 7. (a) I do not own a home. I own a home. (b) I own other property. (c) I do not own a car. If you own, value of home $ _______________________ If checked, value of real estate $ _________________________ Indicate where real estate is located. ________________________________________________ I own a car. If you own, value of car $ _______________________________ Make and Year of car: __________________________________________________________ (d) I have other personal property (jewelry, household contents, etc.) worth $ _______________________ . (OVER) American LegalNet, Inc. www.FormsWorkFlow.com (10/5/11) CCG N041 B (e) I have money in bank accounts in the amount of $________________________________________ (f) I have cash on hand in the amount of $_________________________________________________ (g) I have other assets worth $___________________________________________________________ (h) Total value of assets $______________________________________________________________ Other Income 8. (a) I receive Social Security SSI (including disability) Food stamps/Link card Medical assistance Veteran's Bene¿ts Public assistance Pension bene¿ts Workers' compensation Unemployment compensation Other _____________________________________ (b) Other sources of income (rent, inheritance, etc., if applicable): _________________________________ ________________________________________________________________________________ Under penalty of perjury (a Class 3 felony), I, the undersigned, certify that the above information is true and accurate. ______________________________________ Defendant's Signature ****************************************** ORDER It is ordered that the Public Defender is appointed as counsel to represent the defendant. ENTERED: Dated: ________________________, ___________ __________________________________________ Judge Judge's No. DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS