IN THE CIRCUIT COURT OF THE TWENTY-THIRD JUDICIAL CIRCUIT DEKALB COUNTY, ILLINOIS ___________________________________________ Plaintiff - Judgment Creditor, vs. ___________________________________________ Defendant - Judgment Debtor. ) ) ) ) ) ) ) ) CASE NO.:______________________________ INCOME AND ASSET FORM To Judgment Debtor: Please complete this form and bring it with you to the hearing referenced in the enclosed citation notice. You should also bring to the hearing any documents you have to support the information you provide in this form, such as pay stubs and account statements. The information you provide will help the court determine whether you have any property or income that can be used to satisfy the judgment entered against you in this matter. The information you provide must be accurate to the best of your knowledge. If you fail to appear at this hearing, you could be held in contempt of court and possibly arrested. In answer to the citation and supplemental proceedings served upon the judgment debtor, he or she answers as follows: Name: ______________________________ Home Phone Number: ______________________________ Home Address: ______________________________ Date of Birth: ______________________________ Marital Status: ______________________________ I have __________ dependents. Do you have a job? YES NO Company's name I work for: ________________________ Company's address: ________________________ Job: I earn $ __________ per _________________ If self-employed, list here your business name and address: _______________________________________________________ Income from self-employment is $ __________ per year. I have the following benefits with my employer: _______________________________________________________ I do not have a job, but I support myself through: Government assistance $ __________ per month. Unemployment $ __________ per month. Social Security $ __________ per month. SSI $ __________ per month. Pension $ __________ per month. Other $ __________ per month. (White - Circuit Clerk; Yellow - PL; Pink - DF) Income and Asset Form Rev.: 11/26/2012 American LegalNet, Inc. www.FormsWorkFlow.com Real Estate: Do you own any real estate: YES NO I own real estate at ____________________________ with names of other owners: _____________________________________________________________________________ Additional real estate I own: ______________________________________________________ _____________________________________________________________________________ I have a beneficial interest in a land trust. The name and address of the trustee is: _____________________________________________________________________________. The beneficial interest is listed in my name and _______________________________________. There is a mortgage on my real estate. State the mortgage company's name and address for each parcel of real estate owned: _____________________________________________________________________________ _____________________________________________________________________________ An assignment of beneficial interest in the land trust was signed to secure a loan from _____________________________________________________________________________. I have the following accounts: Checking account at: __________________________ Account balance: $ __________________________ Savings account at: __________________________ Account balance: $___________________________ Money market or certificate of deposit at: ___________________________________________ Safe deposit box at: __________________________ Other accounts (please identify): ______________________________________________ ______________________________________________________________________________ I own: A vehicle (state year, make, model and VIN): _________________________________________ Jewelry (please specify): _______________________________________________ Other property described as: _______________________________________________ _____________________________________________ Stocks/Bonds: ___________________________ Personal computer: ___________________________ DVD player: ___________________________ Television: ___________________________ Stove: ___________________________ Microwave: ___________________________ Work tools: ___________________________ Business equipment: ___________________________ Farm equipment: ___________________________ Other property (please specify): __________________________ ____________________________________________________ Signature: __________________________________________________ (b-10) Any action properly initiated under this Section may proceed notwithstanding an absent or incomplete Income and Asset Form, and a judgment debtor may be examined for the purpose of allowing the judgment creditor to discover income and assets belonging to the judgment debtor or in which the judgment debtor has an interest. (White - Circuit Clerk; Yellow - PL; Pink - DF) Income and Asset Form Rev.: 11/26/2012 American LegalNet, Inc. www.FormsWorkFlow.com