3127 (Rev. 07/06) APPLICATION TO (SUE) (DEFEND) AS AN INDIGENT PERSON UNITED STATES OF AMERICA STATE OF ILLINOIS COUNTY OF DU PAGE IN THE CIRCUIT COURT OF THE EIGHTEENTH JUDICIAL CIRCUIT vs CASE NUMBER File Stamp Here APPLICATION TO SUE OR DEFEND AS AN INDIGENT PERSON I, on oath state On my own behalf, or as: Parent Guardian of Other 1. A. B. C. a disabled person that a minor (name) I have the following occupation or means of subsistance: I am employed as (job) My spouse is employed as (job) My other sources of income or support are: Child Support SSI (Supplemental Security Income) TANF (Temporary Assistance for Needy Families) General Assistance by (employer) by (employer) Food Stamps Maintenance State Children and Family Assistance State Transitional Assistance AABD (Aid to the Aged, Blind and Disabled) Other 2. My family income from all sources, including all sources listed above, (A) for the preceding year was $ (B) currently is $ 3. The persons dependent on me for support are: I am obligated to pay child support in the amount of $ 4. My monthly living expenses (exclusive of payment of debts and child support) are $ 5. I own (A) no real estate except: (location and value) $ exceed $ including a motor vehicle valued at $ ; (B) personal property which in total does not 6. My available income is 125% or less of the current poverty level as established by the U.S. Dept. of Health and Human Services: (see attached schedule): Yes No 7. I am eligible to receive civil legal services (e.g. Legal Aid, or Prairie State Legal Services): Yes Don't Know No 8. I believe in good faith that I have a meritorious claim or defense. 9. I am unable to proceed in this action without payment of fees and costs, and my payment of these fees, costs and charges would result in substantial hardship to my family or me. Name: DuPage Attorney Number: Attorney for: Pro Se Signature of Applicant Signed and sworn to before me Address: Date City/State/Zip: Telephone Number: Circuit Clerk or Notary Public CHRIS KACHIROUBAS, CLERK OF THE 18th JUDICIAL CIRCUIT COURT © WHEATON, ILLINOIS 60189-0707 Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com APPLICATION TO (SUE) (DEFEND) AS AN INDIGENT PERSON 3127 (Rev. 07/06) (735 ILCS 5/5-105) 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; appearance 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 Code are of a nature and value that the court determines that the applicant is able to pay the fees cost, 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, cost, 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. (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. The court shall provide, through the office of the clerk of the court, simplified forms consistent with the requirements of this Section and applicable Supreme Court Rules to any person seeking to sue or defend an action who indicates an inability to pay the fees, costs, and charges of the action. The application and supporting affidavit may be incorporated into a simplified form. The clerk of the court shall post in a conspicuous place in the courthouse a notice no smaller than 8.5 x 11 inches, using no smaller that 30-point typeface printed in English and in Spanish, advising the public that they may ask the court for permission to sue or defend a civil action without payment of fees, costs, and charges. The notice shall be substantially as follows: "If you are unable to pay the fees, costs, and charges of an action you may ask the court to allow you to proceed without paying them. Ask the clerk of the court for forms." (d) The court shall rule on application 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 the moneys 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 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 of the Statute on Statutes. CHRIS KACHIROUBAS, CLERK OF THE 18th JUDICIAL CIRCUIT COURT © WHEATON, ILLINOIS 60189-0707 American LegalNet, Inc. www.FormsWorkflow.com