COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. : IN THE CIRCUIT COURT JUDICIAL SUBPOENA Plaintiff(s) FOR THE THIRD JUDICIAL CIRCUIT -against: MADISON COUNTY, ILLINOIS _________________________________________, Plaintiff vs. : : Case No. __________________ Defendant(s) : ........................................ _________________________________________, . . . . . . . . . . . . . . Defendant AFFIDAVIT THE PEOPLE OF THE STATE OF NEW YORKAND APPLICATION TO SUE OR DEFEND AS AN INDIGENT PERSON TO The undersigned as affiant, under penalty of perjury as provided in Section 735 ILCS 5/1-109, certifies that the statements in this instrument are true and correct, or made on information and belief and believed to be true: 1.) I am familiar with the facts stated herein and this Application to Sue or GREETINGS: Defend as an Indigent Person is brought for: myself as Applicant WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before on behalf of a minor or a disabled adult, ________________________________. , the Honorable at the Court located at County of 2.) The applicant is named as a defendant in a pending action or intends to file a lawsuit. in room , on the day of , 20 , at o'clock in the noon, and at any recessed or3.) adjourned date, to testify and assistance from the witness in this action on the part of the give evidence as a following benefit programs: The applicant receives SSI, AABD, TANF, Food Stamps, General Assistance, State Transitional Assistance, State Children & Family Assistance. (Circle all benefits received.) Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to 4.) the party Thewhose behalf this subpoena was 125% or lessmaximum penalty of $50 and all damagesby the United a on applicant’s household income is issued for a of the current poverty level as established sustained as States result of your failure to comply. Services. Department of Health and Human (Clerk will provide current chart to make this determination.) (You must also provide the following information to confirm your eligibility.) Witness, Honorable , one of the Justices of the Number of persons in applicant’s household ________ Court in County, day of , 20 Household income: $_____________ monthly. The applicant’s household income includes Social Security Disability Payments. (Attorney must sign above and type name below) Unemployment compensation benefits. Attorney(s) for 5.) The applicant is unable to proceed in an action without payment of fees, costs, and charges and the applicant’s payment of those fees, costs, and charges would result in substantial hardship to the applicant or the applicant’s family. 6.) Applicant is: monthly. unemployed, or 7.) Applicant is monthly. married, or 8.) Applicant is employed, and the applicant’s current income is $ ____________ Office and P.O. Address receiving unmarried. The applicant’s spouse’s current income is $____________ Telephone No.: Facsimile No.: paying child support in the amount of $___________ monthly. E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. : 9.) The applicant has the following assets: JUDICIAL Plaintiff(s) money in banks, credit unions and savings & loans, in the amount of $__________ -against: real estate with equity of $_____________ located at ____________________________ automobiles with equity of $ _____________ (Equity is the value of the property minus any mortgage or debt.) : other financial assets, including retirement accounts, of $___________ other assets____________________________________ in the amount of $___________ : SUBPOENA Defendant(s) 10.) The applicant’s total monthly living expenses are $______________ as follows: : ...................................................... (Do not include payments for debts or child support.) Rent or mortgage payment: ___________ Food: ___________ Clothing: _________ Car payment: _________ THEinsurance:_________ Gasoline & maintenance: _________ Utilities: _____________ THE PEOPLE OF Car STATE OF NEW YORK Telephone: ____________ Child care: _____________ Medical, hospital & prescription: _______________ Insurance: _______________ TO Other: _____________________________________________________________________ 11.) The affiant, in good faith, believes that the applicant has a meritorious claim or defense. GREETINGS: Wherefore, the Affiant seeks permission of this Court for the Applicant to sue or defend as an indigent person. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of Affiant in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the ORDER Having Your failure to comply with Sue or Defend is punishable as a contempt of court and willits Order: liable to reviewed the Application to this subpoena as an Indigent Person, the Court now enters make you the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Application ALLOWED. comply. result of your failure to The applicant is allowed to sue or defend as a poor person without payment of fees, costs or charges. Assessment against any other party is reserved pending outcome. Application DENIED for the following reason(s): Witness, Honorable , one of the Applicant is not indigent. Other:___________________________________ Justices of the Court in County, day of , 20 ________________________________. Applicant granted _____ days to pay filing fees. Application is INCOMPLETE. Default Judgment may be entered if application is not completed by the answer date or extension. Applicant granted _____ day extension to submit completed application. RULING RESERVED. Applicant MUST submit most recent Federal incomesign above and type name below) tax return along with year-to-date (Attorney must paycheck stub or statement within _____ days. Failure to do so may result in entry of Default Judgment. __________________________ Date Attorney(s) for __________________________________ Presiding Judge Clerk to mail copies of this Application and Order to all parties of record. Rev. 3-2-04 Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com