IN THE CIRCUIT COURT OF THE TWENTY-SECOND JUDICIAL CIRCUIT McHENRY COUNTY, ILLINOIS __________________________________________ Plaintiff vs. ______________________________________ Defendant Case Number___________________________________________ PETITION AND ORDER TO SUE OR DEFEND AS POOR PERSON Now comes ____________________________________________________________, pursuant to Supreme Court Rule 298 and Section 5/5-105 of the Code of Civil Procedure and on oath states: 1. My occupation or means of subsistence is _______________________________________________________________ 2. My income for the previous year was $__________________________________________________________________ 3. The source and amount of income I currently expect is _____________________________________________________ 4. The nature and value of property owned by me is: a) Real Property___________________________________________________________________________________ b) Personal Property_______________________________________________________________________________ 5. During the preceding year, I have petitioned for permission to sue or defend as a poor person in the following matters:___________________________________________________________________________________________ 6. I am unable to pay the costs of this suit. 7. I have a meritorious claim or defense. 8. I am indigent based on the following criteria (check which applies): (a) I am receiving assistance from the following public benefits programs:_______________________________ _______________________________________________________________________________________ (b) My available income is 125% or less of the current official federal poverty income guidelines; or (c) I am unable to proceed in this action without the payment of costs and if I am required to pay costs, my family or I will suffer substantial hardship. 9. The names of person(s) residing in my family unit are:_____________________________________________________ _________________________________________________________________________________________________ WHEREFORE, Petitioner prays this Court to grant leave to sue or defend as a poor person. VERIFICATION BY CERTIFICATION Under penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, the undersigned certifies that the statements set forth in this instrument are true and correct, except as to matters therein stated to be on information and belief and as to such matters the undersigned certifies as aforesaid that he verily believes the same to be true. ______________________________________________________ Petitioner's Signature IF YOUR PETITION IS GRANTED, THE COURT MAY ORDER YOU TO PAY ALL OR A PORTION OF THE FEES, COSTS, OR CHARGES WAIVED OUT OF MONIES RECOVERED BY YOU PURSUANT TO ANY SETTLEMENT OR JUDGMENT RESULTING IN THIS CASE. ORDER Permission is hereby (granted) (denied) Petitioner to sue or defend as a poor person, and The Sheriff of McHenry County (is) (is not) ordered to serve process upon defendant without fee. The County of McHenry (is) (is not) ordered to pay costs of service by publication. Other:_________________________________________________________________________________________ ______________________________________________________________________________________________ If Petition is denied, reason(s) for denial:___________________________________________________________________ ____________________________________________________________________________________________________ Dated:_________________________________ Entered:______________________________________________________ JUDGE CV-APP1: Revised 12/01/06 American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS To Complete Petition and Order to Sue or Defend as a Poor Person The following explains what information should be included when completing the Petition and Order to Sue or Defend as Poor Person. Now comes____________________, pursuant to Supreme Court Rule 298 and Section 5/5-105 of the Code of Civil Procedure and on oath states: Please print the name of the person who wishes to sue or defend on the blank line. 1. My occupation or means of subsistence is ** **Please print any and all ways that you earn money. 3. The source and amount of income I currently expect is ** **Please print how much money you currently earn OR plan on earning for the week, month or year, whichever is easier for you to calculate. 4. The nature and value of property owned by me is: Real Property Please print any and all type(s) of land or real estate that you own and the approximate value of this property. Personal Property Please print any and all type(s) of personal property, including the value of each item. Personal property includes, but is not limited to money, stock, bonds, cars, boats, electronic goods, or other items that are valuable 5. During the preceding year, I have petitioned for permission to sue or defend as a poor person in the following matters: **Please print any court cases where a court has appointed counsel for you or where you have asked the court to have counsel appointed for you. 8. I am indigent based on the following criteria (check which applies): Based on one of the following reasons (check either box a, b or c), I should be considered a poor person (a) I am receiving assistance from the following public benefits programs: ** **Please print the name of any public aid or benefits program and the amounts received. (b) My available income is 125% or less of the current official Federal Poverty Income Guidelines; Check this box if your income falls below the numbers provided on the following chart U.S. Department of Health & Human Services Poverty Guidelines - 2006 Size of Family Unit Annual Income 125% $9,800 $12,250 1 $13,200 $16,500 2 $16,600 $20,750 3 $20,000 $25,000 4 $23,400 $29,250 5 $26,800 $33,500 6 $30,200 $37,750 7 $33,600 $42,000 8 $4,250 For each member after the eighth add $3,400 9. The names of person(s) residing in my family unit are: ** **Please print the name(s) of all people that reside in your home (apartment, trailer, house) including yourself. The person who wishes to initiate the lawsuit MUST read and sign the oath on the line marked PETITIONER'S SIGNATURE. CV-APP1: Revised 12/01/06 American LegalNet, Inc. www.FormsWorkflow.com