Print Form Application and Affidavit to Sue or Defend as an Indigent Person Clear Form (11/8/07) CCG N689A IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS _________________________________________________________ Plaintiff/Petitioner v. _________________________________________________________ Defendant/Respondent } No. ___________________________________ Calendar ______________________________ APPLICATION AND AFFIDAVIT TO SUE OR DEFEND AS AN INDIGENT PERSON 1. My Name is ______________________________________________ and I am _________________ years old. I live at (do not provide a P.O. Box #) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ My phone number is (________) _______ - ____________. 2. I am filing this application for (check one): ‰ Myself ‰ A minor whose name is ______________________________________________ and who is _________ years old. ‰ An incompetent adult whose name is ________________________________________ and who is _________ years old. ‰ Other (Please explain) _______________________________________________________________________________________________________. 3. I have retained an attorney to represent me in this matter (check one): ‰ Yes ‰ No The attorney’s name is: ________________________________. 4. Assets: I own (check all that apply): ‰ Real Estate, which is located at ___________________________________________________________________________________________. ‰ I estimate the value of the property to be $ _________________. ‰ Automobile or other vehicle - Make ______________________________________ Year ____________ Estimated Value $ ________________ ‰ Jewelry, estimated value $ _________________ ‰ Cash and/or bank accounts in the amount of $ _________________ ‰ Any other property value, estimated value $ _________________ 5. Fill out this section (and skip section #6, below) if you are currently employed: I am employed as a(n) ___________________________________ and the name of my employer is ______________________________________________. My employer can be reached by telephone at (_________) _____________________. During the last year I earned $ _________________ (before taxes). I expect to earn $ _________________ (before taxes) in the upcoming year. My other sources of income are (check all that apply): ‰ SSI ‰ Child Support or Spousal Support (alimony) ‰ Public Aid ‰ Food Stamps or Illinois LINK Card ‰ Family Assistance ‰ Disability ‰ Pension ‰ Social Security ‰ Other (Please specify) _______________ ___________________________________________. The total income from these sources is $ _________________ per month. 6. Fill out this section if you are currently not working: I have been unemployed or retired since _______/ _______/ _______. My last job was as a(n) ________________________________ and my former employer was ______________________________________________. My sources of income are (check all that apply): ‰ Unemployment ‰ SSI ‰ Family Assistance ‰ Public Aid ‰ Food Stamps or Illinois LINK Card ‰ Child Support or Spousal Support (alimony) ‰ Disability ‰ Pension ‰ Social Security ‰ Other (Please specify) ___________________________________________________________. The total income from these sources is $ _________________ per month. Petitioner’s Copy of Application and Affidavit to Sue or Defend as an Indigent Person (Rev. 11/8/07) CCG N689 A 735 ILCS 5/5-105 INFORMATION SHEET FOR LEAVE TO SUE OR DEFEND AS AN INDIGENT PERSON (a) As used in this section: (1) “Fees, costs, and charges” means payments imposed on a party in connection with the prosecution or defense of a civil action, including, but not limited to: filing fees; appearances fees; fees for service of process and other papers served either within or outside this State, including service by publication pursuant to Section 2-206 of this Code and publication of necessary legal notices; motion fees; jury demand fees; charges for participation in, or attendance at, any mandatory process or procedure including, but not limited to, conciliation, mediation, arbitration, counseling, evaluation, “Children First”, “Focus on Children” or similar programs; fees for supplementary proceedings; charges for translation services; guardian ad litem fees; charges for certified copies of court documents; and all other processes and procedures deemed by the court to be necessary to commence, prosecute, defend, or enforce relief in a civil action. 2) “Indigent person” means any person who meets one or more of the following criteria: (i) He or she is receiving assistance under one or more of the following public benefits programs: Supplemental Security Income (SSI), Aid to the Aged, Blind and Disabled (AABD), Temporary Assistance for Needy Families (TANF), Food Stamps, General Assistance, State Transitional Assistance, or State Children and Family Assistance. (ii) His or her available income is 125% or less of the current poverty level as established by the United States Department of Health and Human Services, unless the applicant’s assets that are not exempt under Part 9 or 10 of Article XII of this Code are of nature and value that the court determines that the applicant is able to pay the fees, costs and charges. (iii) He or she is, in the discretion of the court, unable to proceed in an action without payment of fees, costs, and charges and whose payment of those fees, costs, and charges would result in substantial hardship to the person or his or her family. (iv) He or she is an indigent person pursuant to Section 5-105.5 of this Code. [This states that “indigent person” means a person whose income is 125% or less of the current official federal poverty guidelines or who is otherwise eligible to receive civil legal services under the Legal Services Corporation Act of 1974. (42 U.S.C.A. Sec. 2996 et. seq.)] (b) On the application of any person, before or after the commencement of an action, a court, on finding that the applicant is an indigent person, shall grant the applicant leave to sue or defend the action without payment of the fees, costs and charges of the action. (c) An application for leave to sue or defend an action as an indigent person shall be in writing and supported by the affidavit of the applicant or, if the applicant is a minor or an incompetent adult, by the affidavit of another person having knowledge of the facts. The contents of the affidavit shall be established by Supreme Court Rule. (d) The court shall rule on applications under this Section in a timely manner based on information contained in the application unless the court, in its discretion, requires the applicant to personally appear to explain or clarify information contained in the application. If the court finds that the applicant is an indigent person, the court shall enter an order permitting the applicant to sue or defend without payment of fees, costs or charges. If the application is denied, the court shall enter an order to that effect stating the specific reasons for the denial. The clerk of the court shall promptly mail or deliver a copy of the order to the applicant. (e) The clerk of the court shall not refuse to accept and file any complaint, appearance, or other paper presented by the applicant if accompanied by an application to sue or defend in forma pauperis, and those papers shall be considered filed on the date the application is presented. If the application is denied, the order shall state a date certain by which the necessary fees, costs, and charges must be paid. The court, for good cause shown, may allow an applicant whose application is denied to defer payment of fees, costs, and charges, make installment payments, or make payment upon reasonable terms and conditions stated in the order. The court may dismiss the claims or defenses of any party failing to pay the fees, costs, or charges within the time and in the manner ordered by the court. A determination concerning an application to sue or defend in forma pauperis shall not be construed as a ruling on the merits. (f) The court may order an indigent person to pay all or a portion of the fees, costs, or charges waived pursuant to this Section out of monies recovered by the indigent person pursuant to a judgment or settlement resulting from the civil action. However, nothing in this Section shall be construed to limit the authority of a court to order another party to the action to pay the fees, costs, or charges of the action. (g) A court, in its discretion, may appoint counsel to represent an indigent person, and that counsel shall perform his or her duties without fees, charges, or reward. (h) Nothing in this Section shall be construed to affect the right of a party to sue or defend an action in forma pauperis without the payment of fees, costs, or charges, or the right of a party to court appointed counsel, as authorized by any other provision of law or by the rules of the Illinois Supreme Court. (i) The provisions of this Section are severable under Section 1.31 the Statute on Statutes. See (5 ILCS 70/1.31) DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS (2/20/08) CCG N689 B 7. Fill out this section if you are currently married. My spouse’s name is______________________________________________. My spouse is (check one): Employed as a(n) __________________________________ and the name of his/her employer is ______________________________________. During the last year my spouse earned $ _________________ (before taxes). My spouse expects to earn $ _________________ (before taxes) in the upcoming year. Unemployed as of ____________________. Retired and is receving social security benefits and/or a pension in the amount of $ ______________ per month. 8. Dependents: The following are the names and ages of the minor children and any other people who are dependent on me for support (List full name and age): ________________________/ __________ _____________________________/ __________ _____________________________/ __________ ________________________/ __________ _____________________________/ __________ _____________________________/ __________ 9. Other Expenses: I am paying child support in the amount of $ ______________ per month. I am paying spousal support (alimony) in the amount of $ ______________ per month. My monthly living expenses (not including child or spousal support payments) in the amount of $ ______________ per month. 10. Under the penalty of perjury (a Class 3 Felony), I, the undersigned, certify (answer yes or no to each statement and sign your name.) 2) Please also submit: a. Order to Sue or Defend as an Indigent Person b. Legible copy of all pleadings (Not required in Domestic Relations cases) 3) You may be required to submit: a. Photo ID Yes No I have knowledge of the facts stated in this application. Yes No To the best of my knowledge, the statements set forth in this application are true and correct. Yes No I believe in good faith that I have a meritorious claim or defense. Yes 1) This application must be completely filled out. No I am unable to proceed in this action if required to pay the fees, costs, and charges Yes No I and/or my family will suffer substantial hardship if required to pay the fees, costs, and charges. Yes No I have reviewed the United States Department of Health and Human Services Poverty Guidelines and belive my income is 125% or less of the current poverty level. Atty. No.: ____________________ Name: __________________________________________________________ Atty. for: _______________________________________________________ _______________________________________________________________ Signature of Applicant Address: _____________________________________________________ City/State/Zip:___________________________________________________ Telephone: ______________________________________________________ Dated: ___________________________________________, ____________ DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS