Illinois Court of Claims Office of the Secretary of State 630 S. College St., Springfield, IL 62756 Application to Sue or Defend as a Poor Person IN THE COURT OF CLAIMS, STATE OF ILLINOIS ) ) ) ) ) ) ) ) vs. ORDER _____ Application Granted _____ Application Denied _____________ , 20 _____ _______________________ No. Judge I, ______________________________________________________________________________________________________________ ❑ on my own behalf ❑ as _______________________________________________________ , on behalf of ___________________________________ , Parent, Guardian, Other Name a ________________________________________________ called “applicant” on oath state: Minor, Incompetent 1. Applicant’s occupation or means of support: a. Applicant is employed as ______________________________________ by ______________________________________ . Job Employer 2. Applicant’s income for the preceding year: $ ________________________________________________________________ . 3. Sources and amount of income expected by applicant hereafter: _______________________________________________ ____________________________________________________________________________________________________________ 4. Persons dependent on applicant for support: __________________________________________________________________ ____________________________________________________________________________________________________________ 5. Applicant owns (a) no real estate except: (State Address or Location, Nature of Improvements and Value) ________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ and (b) personal property, which in the aggregate does not exceed $ _________________ in value and consists of: ___________________________________________________________________________________________________________ , including a __________________________ motor vehicle, ________________________ valued at $ ___________________ . Make Year 6. No applications were filed by or on behalf of applicant for leave to sue or defend as a poor person during the preceding year except: ______________________________________________________________________________________ ____________________________________________________________________________________________________________ 7. Applicant is unable to pay the costs of this case. 8. Applicant has a meritorious _________________________________________________________________________________ Claim Printed by authority of the State of Illinois - March 2005 - 500 - CC-90 Defense American LegalNet, Inc. www.USCourtForms.com NOTE: If incarcerated at the time of this application, a certified copy of the inmate’s trust fund must be attached to this application. ________________________________________________ Signature Signed and sworn to before me ____________________________________ , 20 ________ ________________________________________________ Notary Public ________________________________________________ Name ________________________________________________ Attorney for Application ________________________________________________ Street Address ________________________________________________ City ________________________________________________ Telephone This state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under 705 ILCS 505/1 et seq. Disclosure of this information is REQUIRED. Failure to provide any information will result in this form not being processed. Printed by authority of the State of Illinois - March 2005 - 500 - CC90 American LegalNet, Inc. www.USCourtForms.com