CIRCUIT COURT OF ILLINOIS JUDICIAL CIRCUIT COUNTY Plaintiff, vs. Case No. [File stamp] Defendant. APPLICATION TO SUE OR DEFEND AS A POOR PERSON [ Applicant, , respectfully requests the court to grant him/her leave to [ ]defend as a poor person and in support thereof states, under oath, the following facts are true: I am the [ ]plaintiff [ ]defendant in the above captioned legal proceedings. I believe, in good faith, I have a meritorious claim/defense. I am a poor person as defined by 735 ILCS 5/5-105 and unable to [ ] prosecute [ unable to pay the costs, fees and charges herein because: 1. [ ] sue ] defend this action and am ] I am 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, or 2. [ ] My family unit contains people (including myself) and the total available income of the family is 125% or less of the current poverty level as established by the United States Department of Health and Human Services, or 3. [ ]I am being represented by legal aid or other civil legal services provider as defined in 735 ILCS 5/5-105.5, or 4. [ ]I am unable to proceed in this action without payment of fees, costs and charges and the payment of said fees, costs, and charges would result in substantial hardship to me and/or my fitmily. EMPLOYMENT 5. [ ]I am not employed. and my take-home pay is [ ] weekly [ ]I am employed by [ ]bi-weekly [ ] monthly. [ ]My spouse is living with me and is not employed. and has take-home pay [ ]My spouse is living with me, is employed by of [ ] weekly [ ] bi-weekly [ ] monthly (including all wages, tips and overtime). CHILD SUPPORT 6. I am [ ] receiving [ ] paying child support in the sum of support [ ] is not in arrears [ ] is in arrears in the sum of [ ] weekly [ ]bi-weekly [ . ] monthly. Child DEBTS 7. [ ] I owe the following debts: TO: Monthly Payment in the sum of " " TOTAL American LegalNet, Inc. www.USCourtForms.com LIVING EXPENSES 8. My MONTHLY living expenses (excluding payment of debts and child support) for me and my family are . ASSETS 9. I own the following: (Address) [ ] House (Value) (Year/type) [ ] Car/Truck (Value) (Year/type) [ ] Motorcycle (Value) (Year/type) [ ] Recreational Vehicle (Value) in a savings account. in a checking account. [ ] I have [ ] I have from [ ] I have other income in the sum of (source of income) [ ] The following things affect my ability to pay costs (disabilities, health problems, etc.): AFFIDAVIT Applicant, after being duly sworn and upon penalty of pedury, hereby certifies that the statements set forth in this application are true and correct. Applicant SUBSCRIBED AND SWORN TO before me this day of , 20___. Circuit Clerk/Notary [ ORDER , Courtroom ]Application set for hearing on . Clerk to give notice to Applicant. (Date/time) Judge (Date entered) APPLICATION APPROVED (date). Clerk to give notice to Applicant. [ ]Application approved on [ ]Applicant to pay fees, costs and charges out of anyjudgment or settlement received. (Date entered) Judge [ APPLICATION DENIED (date). Clerk to give notice to Applicant ]Application denied on Specific reason (date). deferred until [ ]Payment of costs, fees and charges in the sum of If not paid by said date, cause dismissed. [ ] For good cause shown, Applicant to make instalment payments on said costs in the sum of and a like amount each [ ]weekly [ ] bi-weekly [ ] monthly commencing on are paid m full. [ ]week [ ]two weeks [ ]month until total costs, fees and charges in the sum of (Date entered) Judge 2 American LegalNet, Inc. www.USCourtForms.com