IN THE CIRCUIT COURT TWENTIETH JUDICIAL CIRCUIT ST. CLAIR COUNTY, ILLINOIS ) ) ) ) ) vs. No. INCOME AND ASSET FORM To Judgment Debtor: Please complete this form and bring it with you to the hearing referenced in the enclosed citation notice. You should also bring to the hearing any documents you have to support the information you provide in this form, such as pay stubs and account statements. The information you provide will help the court determine whether you have any property or income that can be used to satisfy the judgment entered against you in this matter. The information you provide must be accurate to the best of your knowledge. If you fail to appear at this hearing, you could be held in contempt of court and possibly arrested. In answer to the citation and supplemental proceedings served upon the judgment debtor, he or she answers as follows: Name Home Phone Number Home Address Date of Birth Marital Status: I have ________dependents. Do you have a job? YES Company's name I work for Company's address NO Job: I earn $_______ per_________ If self employed, list here your business name and address: Income from self employment is $_________________ per year. I have the following benefits with my employer: I do not have a job, but I support myself through: Government Assistance $ per month Unemployment $ per month Social Security $ per month SSI $ per month Pension $ per month Other $ per month Case No. , Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Real Estate: Do you own any real estate? YES NO I own real estate at with names of other owners Additional real estate I own I have a beneficial interest in a land trust. The name and address of the trustee is: The beneficial interest is listed in my name and There is a mortgage on my real estate. State the mortgage company's name and address for each parcel of real estate owned: An assignment of beneficial interest in the land trust was signed to secure a loan from I have the following accounts: Checking account at Savings account at Money market or certificate of deposit at Safe deposit box at Other accounts (please identify) account balance $ account balance $ I own: A vehicle (state year, make, model, and VIN) Jewelry (please specify): Other property described as Stocks/Bonds Personal computer DVD player Television Stove Microwave Work tools Business equipment Farm equipment Other property (please specify) Signature: Any action properly initiated under this Section may proceed notwithstanding an absent or incomplete Income and Asset Form, and a judgment debtor may be examined for the purpose of allowing the judgment creditor to discover income and assets belonging to the judgment debtor or in which the judgment debtor has an interest. Case No. Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com