Free CCG N689 B 2-20-08.pmd - Illinois

(2/20/08) CCG N689 B

7. Fill out this section if you are currently married. My spouse's name is______________________________________________. My spouse is (check one): Employed as a(n) __________________________________ and the name of his/her employer is ______________________________________. During the last year my spouse earned $ _________________ (before taxes). My spouse expects to earn $ _________________ (before taxes) in the upcoming year. Unemployed as of ____________________. 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 minor children and any other people who are dependent on me for support (List full name and age): ________________________/ __________ ________________________/ __________ 9. Other Expenses: I am paying child support in the amount of $ ______________ per month. I am paying spousal support (alimony) in the amount of $ ______________ per month. 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: a. Order to Sue or Defend as an Indigent Person b. Legible copy of all pleadings (Not required in Domestic Relations cases) 3) You may be required to submit: a. Photo ID

Yes Yes

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, costs, and charges

Yes Yes

Yes

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.

Yes

Atty. No.: ____________________ Name: __________________________________________________________ Atty. for: _______________________________________________________ Address: _____________________________________________________ City/State/Zip:___________________________________________________ Telephone: ______________________________________________________ Dated: ___________________________________________, ____________ _______________________________________________________________ Signature of Applicant

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