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Application And Affidavit To Sue As An Indigent Person Form. This is a Illinois form and can be use in Office Of The State Appellate Defender Statewide.
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Tags: Application And Affidavit To Sue As An Indigent Person, Illinois Statewide, Office Of The State Appellate Defender
IN THE CIRCUIT COURT OF THE ___________________JUDICIAL CIRCUIT
_____________________________COUNTY, ILLINOIS
[ ] THE PEOPLE OF THE STATE OF ILLINOIS )
or
)
[ ] A MUNICIPAL CORPORATION,
)
)
vs.
)
)
_________________________________
)
Defendant/Petitioner.
)
CASE NO. ________________
APPLICATION AND AFFIDAVIT TO SUE AS AN INDIGENT PERSON
COMES NOW, _____________________________, Defendant/Petitioner herein, age
_________, pursuant to 735 ILCS 5/5-105, and Petitions this Court for leave to sue as an
indigent person. In support of this Petition, Defendant/Petitioner states as follows:
‘
1.
I am employed as a(n): ____________________ Annual gross salary $__________
Employer: ____________________________________________________
(Name of Employer)
_____________________________________________________
(Street Address)
_____________________________________________________
(City)
(State)
(ZIP)
OR
I am unemployed as of ______________________________.
(Date of unemployment)
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Last employer:______________________________________________________
(Name of Employer)
______________________________________________________
(Street Address)
______________________________________________________
(City)
(State)
(ZIP)
I began receiving unemployment compensation on _________________ in the amount of
(Date)
$______________________ per month.
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2.
My spouse is employed as a(n): _______________ Annual gross salary $________
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Spouse’s employer:_____________________________________________________
(Name of Employer)
_____________________________________________________
(Street Address)
______________________________________________________
(City)
(State)
(ZIP)
OR
My spouse is unemployed as of ______________________________.
‘
(Date of unemployment)
Last employer:______________________________________________________
(Name of Employer)
______________________________________________________
(Street Address)
______________________________________________________
(City)
(State)
(ZIP)
My spouse began receiving unemployment compensation on ______________ in the amount of
(Date)
$______________________ per month.
3. My other sources of income are: SSI
Public Aid
Child Support
Family Assistance
Foster Care Aid to the Aged, Blind and Disabled Temporary Assistance for Needy
Families General Assistance State Transitional Assistance State Children and Family
Assistance Other:_____________________________________________________________
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Totaling ______________________________________ $ per month
4.
My available income is 125% or less of the current poverty level established by the State
Department of Health and Human Services.
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5. The nature and value of property I own includes:
Real Estate (Describe property, specify address, present value and mortgage and liens
outstanding)___________________________________________________________________
Cash, Bank accounts, etc.$__________________ Clothing and jewelry $________________
Furniture appliances, household goods $___________________________________________
Automobile–Model________________ Year______________ Value $___________________
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6. The names and ages of persons dependent on the applicant for support are:
__________________________/___________ __________________________/___________
(Name)
(Age)
(Name
(Age)
__________________________/___________ __________________________/___________
(Name)
(Age)
(Name
(Age)
__________________________/___________ __________________________/___________
(Name)
(Age)
(Name
(Age)
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7. I am paying child support in the amount of $___________________per ________________.
8. I am paying spousal support in the amount of $_____________________ per ____________.
9. My monthly living expenses (not including payment of debts and child support) are $______.
10. I am unable to pay the costs of this case and to do so would cause a substantial hardship to
me and my family.
‘
I am eligible to receive civil legal services as defined in 735 ILCS 5/5-1015.5.
‘
11.
WHEREFORE, the Defendant/Petitioner prays that this Court grant
Defendant/Petitioner leave to sue as an indigent 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, as to such matters the
undersigned certifies as aforesaid he/she verily believes the same to be true.
__________________________________
Date
_____________________________________
Defendant/Petitioner
Subscribed and sworn to before me this _____ day of ___________________, 20____.
_______________________________________
Notary/Clerk
__________________________________________________________________________
Prepared by:
Name______________________________
Address____________________________
City/State/Zip_______________________
Atty No.________________________
Attorney for _____________________
Telephone_______________________
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