STATE OF ILLINOIS) )SS COUNTY OF WILL ) IN THE CIRCUIT COURT OF THE TWELFTH JUDICIAL CIRCUIT WILL COUNTY, ILLINOIS ________________________________________ Petitioner VS CASE NO.__________________________ ________________________________________ Defendant G Order application to (sue) (defend) as a poor person is granted. G Order application to (sue) (defend) as a poor person is denied. DATE:______________________________________ ENTER:_____________________________________ (Judge) APPLICATION TO SUE OR DEFEND AS A POOR PERSON I, G on my own behalf as G Parent G Guardian G Other ________________________________________ of ________________________________________________, a_______________________________________________ (Name) (Minor) (Incompetent) 1. Applicant’s occupation or means of subsistence: A. Applicant is employed as ________________________________________________________________________________________ (Job) by___________________________________________________________________________________________________________ (Employer) B. Applicant’s other sources of income or support are:____________________________________________________________________ ______________________________________________________________________________________________________________ 2. Applicant’s income for the preceding year was $__________________________________________________________________________ 3. The sources and amount of income expected by the applicant hereafter are:_____________________________________________________ ____________________________________________________________________________________________________________________ The person dependent on applicant for support are:_______________________________________________________________________ _________________________________________________________________________________________________________________ 4. Applicant owns A. No real estate except: (Location and Value)_________________________________________________________________________ B. Personal property which in the aggregate does not exceed $______________________________________________________________ and consists of:_________________________________________________________________________________________________ including a _____________________________________________motor vehicle, valued at $___________________________________ 5. No applications were filed by or on behalf of application for leave to sue or defend as a poor person during the preceding year except:___________________________________________________________________________________________________________ 6. Applicant is unable to pay the fees, costs, and charges of this case. 7. Applicant has a meritorious G Claim G Defense Subscribed and Sworn before me Date:_______________________________ ___________________________________________ (Signature of Applicant) _______________________________________ (Notary Public - Circuit Court Clerk) Attorney’s Name:_________________________________________ ARDC#:________________________________________________ Address:________________________________________________ City:___________________________________________________ Telephone:______________________________________________ 2000 © American LegalNet, Inc.