IN THE CIRCUIT COURT FOR THE SIXTEENTH JUDICIAL CIRCUIT DEKALB COUNTY, ILLINOIS Plaintiff,______________________________ vs. Defendant,____________________________ ) ) ) ) ) ) Case No.___________________________________ APPLICATION FOR FEE WAIVER PURSUANT TO SUPREME COURT RULE 298 I, ______________________________, in this case, on oath state that I am without adequate funds and assets to pay the fees, and that I make the following statement in support of my request to waive fees and costs. Name_______________________________________ Address____________________________________ D.O.B.:____/___/___ Telephone__________________ City_______________________State____________ Family: Marital Status_____________Number of Children________Number of other dependents___________ Their Relationship___________________________________________________________________ Name and Address of Employer:_______________________________________________________________ ______________________________________________________________________________________ Sources of Income: $__________ per month from employment. $_______________ per month pension, trusts, annuity, welfare, Workman’s Compensation, retirement, or disability plan, or any similar State, Federal, local, or private benefit plan. $_______________ per month for other sources listed here:___________________________________ Value of Assets: Home or dwelling $___________________________________________________________ Other real property $____________________Location_______________________________________ Car $____________________Make______________________________________Year____________ Other personal property $__________________________________Bank Accounts $_______________ Cash on Hand $________________Surrender value of life/annuity policies $______________________ Securities, Trusts, Bonds $__________________________, Other Assets $_______________________ Description____________________________________________________________________________ Liabilities: Mortgage on home $_______________________, Monthly Housing Payment $________________ Amount owed on car $_________________Personal Debts $_____________ To whom_____________ Other Liabilities and debts $____________________ To whom owed____________________________ I am unable to pay the costs of the suit. I, under penalties or perjury, certify the foregoing is a true and complete statement of all my assets and income. _________________________________________ Signature of Applicant Subscribed and sworn to before me _________________________, 20_____ _________________________________ Judge/Clerk ORDER The application for fee waiver is: [ ] APPROVED [ ] DENIED [ ] DENIED, however payment of the costs are deferred to _____/_____/_____. Enter:________________________________________ Judge Date:_________________________________, 20_____ feewaiver1 4/3/06 American LegalNet, Inc. www.FormsWorkflow.com