Free CCCR 0012 2-09-04 - Illinois

Application, Affidavit and Order to Defend as an Indigent Person in a Criminal or Traffic Matter IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS PEOPLE OF THE STATE OF ILLINOIS or

(7/11/06) CCG 0690

___________________________________________________,
v. A Municipal Corporation,

___________________________________________________,
Defendant/Applicant

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Case No. ______________________________

APPLICATION, AFFIDAVIT AND ORDER TO DEFEND AS AN INDIGENT PERSON
I, ________________________________________________________ on oath state,
(Name)

On my own behalf, OR as

Parent, Minor

Guardian, OR

Other ___________________________ on behalf of __________________________________ a(n)

Incompetent Adult: 1. I am employed as a(n) ________________________________________________________________________________ by _______________________________________________________________________________________________. 2. My other sources of income (including spouse's income) or support are: __________________________________________

_______________________________________________________________________________________________. 3. The amount of income that I expect for this year is $ __________________________. 4. My income for the previous year was $ ____________________________________. 5. The person(s) dependent on me for support are: ________________________________________________________.
6. My other sources of income are: SSI Public Aid Foster Care Aid to the Aged, Blind and Disabled General Assistance State Transitional Assistance 7. The nature and value of property I own includes: mortgage and liens outstanding.) Child Support Food Stamps Family Assistance Temporary Assistance for Needy Families State Children and Family Assistance

Other: ________________________________________________ $ ___________________________ (per month). Real Estate (Describe property, specify address, present value and

_______________________________________________________________________________________________ _______________________________________________________________________________________________ Cash, bank accounts, etc. $ ____________________________ Clothing and jewelry $ ______________________ Motor vehicle - Model ______________________________ Year _________ Value $ ______________________. 8. My monthly living expenses, including payment of debts and child support, are $ __________________________________.
9. I am unable to pay the costs of this case, and to do so would cause a substantial hardship on me and my family. Name: _________________________________________________ Firm/Business Name: ____________________________________ Address: _______________________________________________ City/State/Zip: __________________________________________ Telephone: _____________________________________________ ORDER It is hereby ordered: The applicant is permitted to defend without payment of fees, costs or charges. The application is denied. ENTERED Dated: ______________________________, ___________

Under penalties of perjury and/or contempt of court, 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 s/he verily believes the same to be true.

________________________________________________
Signature of Applicant

_______________________________________________
Judge Judge's No.

DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS