STATE OF ILLINOIS IN THE CIRCUIT COURT OF THE 22nd JUDICIAL CIRCUIT McHENRY COUNTY PEOPLE OF THE STATE OF ILLINOIS Case Number__________________________________ vs. Ticket Number_________________________________ ________________________________________ Defendant Arresting Agency_______________________________ MANDATORY INSURANCE AFFIDAVIT I,______________________________________________________ being first duly sworn upon oath deposes and states as follows: 1. That I am a defendant in the above pending matter before the Twenty-Second Judicial Circuit for a violation of Failure to Carry an Insurance Identification Card as required by 7-601 of the Mandatory Insurance Code; 2. That I was presented a citation for violation of the Illinois Mandatory Insurance Act on ____________________________________, and at the time I was presented with the citation, I was covered by insurance as required by the Illinois Mandatory Insurance Act; 3. That the Certificate of Insurance issued by my insurance company__________________________ under policy number ______________________________________________________________ which began on ________________________ and expires on ____________________________; 4. I FURTHER UNDERSTAND THAT IF I FURNISH FALSE INFORMATION ON THIS AFFIDAVIT THAT I MAY BE ARRESTED FOR THE OFFENSE OF PERJURY WHICH IS A FELONY UNDER ILLINOIS LAW. ___________________________________________________ Defendant's Signature ___________________________________________________ Address ___________________________________________________ City, State Zip SWORN AND SUBSCRIBED before me ___________________________________________________ ____________________________________, 20________ _______________________________________________ Notary Public / Circuit Clerk Phone Number If this box is checked, proof of insurance was furnished before Circuit Clerk received above-mentioned ticket from arresting agency. Circuit Clerk will hold proof of insurance until ticket is received. It is defendant's responsibility to verify that Circuit Clerk received abovementioned ticket and the case has been administratively dismissed. Please check back with Circuit Clerk Criminal/Traffic Division at (815)334-4190 or www.mchenrycircuitclerk.org to check case status. American LegalNet, Inc. www.FormsWorkFlow.com CR-AFF1: Revised 5/15/2014