Free CCG N689 A 11-8-07.pmd - Illinois

Application and Affidavit to Sue or Defend as an Indigent Person IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS

(11/8/07) CCG N689A

Print Name of Person or Party Suing _________________________________________________________
Plaintiff/Petitioner v.

Print Name of Person or Party Being Sued _________________________________________________________
Defendant/Respondent

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Print Your Case Number No. ___________________________________
Calendar

______________________________

APPLICATION AND AFFIDAVIT TO SUE OR DEFEND AS AN INDIGENT PERSON
Print Your Name Print Your Age 1. My Name is ______________________________________________ and I am _________________ years old.
I live at (do not provide a P.O. Box #)

Print Your Home Address __________________________________________________________________ Print Your Home Address Unit Number __________________________________________________________________ Print Your Home Address City, State and Zip __________________________________________________________________

Print Age My phone number is (________) _______ - ____________.
2. I am filing this application for (check one): Myself

Other (Please explain) _______________________________________________________________________________________________________. 3. I have retained an attorney to represent me in this matter (check one): 4. Assets: I own (check all that apply): Yes No The attorney's name is: ________________________________.

Real Estate, which is located at ___________________________________________________________________________________________.

Amount I estimate the value of the property to be $ _________________.

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SSI Disability

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Public Aid Pension SSI Public Aid Disability

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Social Security Pension

Minor's Name, if applicable Age A minor whose name is ______________________________________________ and who is _________ years old. Incompetent Adult Name, if applicable Age An incompetent adult whose name is ________________________________________ and who is _________ years old.

Automobile or other vehicle - Make ______________________________________ Year ____________ Amount Jewelry, estimated value $ _________________

Amount Estimated Value $ ________________

Amount Cash and/or bank accounts in the amount of $ _________________
Amount Any other property value, estimated value $ _________________
5. Fill out this section (and skip section #6, below) if you are currently employed: Job Title Employer's Name I am employed as a(n) ___________________________________ and the name of my employer is ______________________________________________.
Employer Annual Salary My employer can be reached by telephone at (_________) _____________________. During the last year I earned $ _________________ (before
Next Annual Salary taxes). I expect to earn $ _________________ (before taxes) in the upcoming year.

My other sources of income are (check all that apply): Child Support or Spousal Support (alimony)

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Food Stamps or Illinois LINK Card

Family Assistance

Other (Please specify) _______________

___________________________________________. Amount The total income from these sources is $ _________________ per month. 6. Fill out this section if you are currently not working:

Last Job Title I have been unemployed or retired since _______/ _______/ _______. My last job was as a(n) ________________________________ and my former Last Employer's Name employer was ______________________________________________.
My sources of income are (check all that apply): Family Assistance Unemployment Food Stamps or Illinois LINK Card Social Security Other (Please

Child Support or Spousal Support (alimony)

specify) ___________________________________________________________.

Amount The total income from these sources is $ _________________ per month.

Petitioner's Copy of Application and Affidavit to Sue or Defend as an Indigent Person 735 ILCS 5/5-105

(Rev. 11/8/07) CCG N689 A

INFORMATION SHEET FOR LEAVE TO SUE OR DEFEND AS AN INDIGENT PERSON
(a) As used in this section: (1) "Fees, costs, and charges" means payments imposed on a party in connection with the prosecution or defense of a civil action, including, but not limited to: filing fees; appearances fees; fees for service of process and other papers served either within or outside this State, including service by publication pursuant to Section 2-206 of this Code and publication of necessary legal notices; motion fees; jury demand fees; charges for participation in, or attendance at, any mandatory process or procedure including, but not limited to, conciliation, mediation, arbitration, counseling, evaluation, "Children First", "Focus on Children" or similar programs; fees for supplementary proceedings; charges for translation services; guardian ad litem fees; charges for certified copies of court documents; and all other processes and procedures deemed by the court to be necessary to commence, prosecute, defend, or enforce relief in a civil action. 2) "Indigent person" means any person who meets one or more of the following criteria: (i) He or she is receiving assistance under one or more of the following public benefits programs: Supplemental Security Income (SSI), Aid to the Aged, Blind and Disabled (AABD), Temporary Assistance for Needy Families (TANF), Food Stamps, General Assistance, State Transitional Assistance, or State Children and Family Assistance. (ii) His or her available income is 125% or less of the current poverty level as established by the United States Department of Health and Human Services, unless the applicant's assets that are not exempt under Part 9 or 10 of Article XII of this Code are of nature and value that the court determines that the applicant is able to pay the fees, costs and charges. (iii) He or she is, in the discretion of the court, unable to proceed in an action without payment of fees, costs, and charges and whose payment of those fees, costs, and charges would result in substantial hardship to the person or his or her family. (iv) He or she is an indigent person pursuant to Section 5-105.5 of this Code. [This states that "indigent person" means a person whose income is 125% or less of the current official federal poverty guidelines or who is otherwise eligible to receive civil legal services under the Legal Services Corporation Act of 1974. (42 U.S.C.A. Sec. 2996 et. seq.)] (b) On the application of any person, before or after the commencement of an action, a court, on finding that the applicant is an indigent person, shall grant the applicant leave to sue or defend the action without payment of the fees, costs and charges of the action. (c) An application for leave to sue or defend an action as an indigent person shall be in writing and supported by the affidavit of the applicant or, if the applicant is a minor or an incompetent adult, by the affidavit of another person having knowledge of the facts. The contents of the affidavit shall be established by Supreme Court Rule. (d) The court shall rule on applications under this Section in a timely manner based on information contained in the application unless the court, in its discretion, requires the applicant to personally appear to explain or clarify information contained in the application. If the court finds that the applicant is an indigent person, the court shall enter an order permitting the applicant to sue or defend without payment of fees, costs or charges. If the application is denied, the court shall enter an order to that effect stating the specific reasons for the denial. The clerk of the court shall promptly mail or deliver a copy of the order to the applicant. (e) The clerk of the court shall not refuse to accept and file any complaint, appearance, or other paper presented by the applicant if accompanied by an application to sue or defend in forma pauperis, and those papers shall be considered filed on the date the application is presented. If the application is denied, the order shall state a date certain by which the necessary fees, costs, and charges must be paid. The court, for good cause shown, may allow an applicant whose application is denied to defer payment of fees, costs, and charges, make installment payments, or make payment upon reasonable terms and conditions stated in the order. The court may dismiss the claims or defenses of any party failing to pay the fees, costs, or charges within the time and in the manner ordered by the court. A determination concerning an application to sue or defend in forma pauperis shall not be construed as a ruling on the merits. (f) The court may order an indigent person to pay all or a portion of the fees, costs, or charges waived pursuant to this Section out of monies recovered by the indigent person pursuant to a judgment or settlement resulting from the civil action. However, nothing in this Section shall be construed to limit the authority of a court to order another party to the action to pay the fees, costs, or charges of the action. (g) A court, in its discretion, may appoint counsel to represent an indigent person, and that counsel shall perform his or her duties without fees, charges, or reward. (h) Nothing in this Section shall be construed to affect the right of a party to sue or defend an action in forma pauperis without the payment of fees, costs, or charges, or the right of a party to court appointed counsel, as authorized by any other provision of law or by the rules of the Illinois Supreme Court. (i) The provisions of this Section are severable under Section 1.31 the Statute on Statutes. See (5 ILCS 70/1.31) DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS

(5/02/07) CCG N689 B

7. Fill out this section if you are currently married.

Print Spouse's Name My spouse's name is______________________________________________. My spouse is (check one):

Spouse's Job Title, if applicable Spouse's Employer's Name Employed as a(n) __________________________________ and the name of his/her employer is ______________________________________.
Next Annual Salary Annual Salary During the last year my spouse earned $ _________________ (before taxes). My spouse expects to earn $ _________________ (before taxes) in the

upcoming year. Unemployed as of ____________________.

Amount Retired and is receving social security benefits and/or a pension in the amount of $ ______________ per month.
8. Dependents: The following are the names and ages of the people who are dependent on me for support (List full name and age): Full Name Age ________________________/ __________ _____________________________/ __________ _____________________________/ __________ ________________________/ __________ 9. Other Expenses: _____________________________/ __________ _____________________________/ __________

Amount My monthly living expenses (not including child or spousal support payments) in the amount of $ ______________ per month.
10. Under the penalty of perjury (a Class 3 Felony), I, the undersigned, certify (answer yes or no to each statement and sign your name.)

1) This application must be completely filled out. 2) Please also submit: Indigent Person

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a. Order to Sue or Defend as an b. Legible copy of all pleadings 3) You may be required to submit: a. Photo ID

Print "Pro Se - 99500" If No Attorney Atty. No.: ____________________

Print Your Name Name: __________________________________________________________ If No Attorney, Leave Blank Atty. for: _______________________________________________________
Print Your Address Address: _____________________________________________________

Print City, State and Zip City/State/Zip:___________________________________________________
Print Complete Phone Number Telephone: ______________________________________________

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

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Yes Yes Yes Yes Yes

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Yes costs, and charges

No I have knowledge of the facts stated in this application.

No To the best of my knowledge, the statements set forth in this application are true and correct. No I believe in good faith that I have a meritorious claim or defense. No I am unable to proceed in this action if required to pay the fees,

No I and/or my family will suffer substantial hardship if required to pay the fees, costs, and charges. No I have reviewed the United States Department of Health and Human Services Poverty Guidelines and belive my income is 125% or less of the current poverty level.

_______________________________________________________________ Signature of Applicant

Dated: ___________________________________________, ____________

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Amount I am paying child support in the amount of $ ______________ per month. Amount I am paying spousal support (alimony) in the amount of $ ______________ per month.