Free Matt Melucci - Illinois

MATT MELUCCI
Madison County Clerk of Court Madison County Courthouse, 155 North Main Street, Edwardsville, IL 62025-1950 (618) 296-4420

DISSOLUTION OF MARRIAGE
Two types of divorce described below are available through the courts: 1) standard dissolution of marriage and 2) joint simplified dissolution of marriage. 1. Standard Dissolution of Marriage applies to most couples. If any one of the following criteria applies to a married couple seeking divorce, they must file a standard dissolution of marriage: you had children born to or adopted by you, or the wife is now pregnant; you own real estate; you have been married 8 or more years; your joint earnings are $35,000 or more annually; either spouse earns more than $20,000 annually, you have marital property valued in excess of $10,000.

A standard dissolution of marriage requires a $338.00 in filing fees ($219 to file the case; $119 for an answer) payable to the Circuit Clerk when the case is filed at the Circuit Clerk's office. Only two forms are available at this site that relate to filing a standard dissolution of marriage: an Entry of Appearance form and an Affidavit of Military Service. Both of these forms must be signed in front of a Notary Public. To view these two forms, scroll down to the bottom of this site. To learn more about how to prepare a petition and judgment for dissolution of marriage, consult your attorney. If you do not have an attorney, or cannot afford one, information is available from the law library in the basement of the courthouse.

2.

Joint Simplified Dissolution is available on a strictly limited basis. Under a joint simplified proceeding, each spouse loses any right to maintenance, or alimony as it is more commonly known. Generally, joint simplified dissolution applies only to couples for whom all of the following apply. The couple: have been married less than 8 years, do not have children born to or adopted by them have total earnings of less than $35,000 a year, and neither spouse earns more than $20,000 annually own no real estate, and have marital property valued at or less than $10,000. For a complete listing of eligibility requirements for simplified joint dissolution cases, continue to scroll down through this site, or print all pages at this site. A joint simplified dissolution requires a $219.00 filing fee payable to the Circuit Clerk when the case is filed at the Circuit Clerk's office. If you are unable to afford the filing fee, you may complete the form entitled "Application to Sue or Defend as an Indigent Person." This form and others needed to file for a joint simplified dissolution of marriage are available at this site. Scroll down to view the various forms.

General Information Concerning Dissolution of Marriages (Divorce)

A dissolution of marriage (commonly referred to as a divorce) is a serious legal step which should only be taken after careful and considerable thought. If you are considering such a proceeding, you should note the following: It is in the best interests of each of the parties to consult attorneys regarding the dissolution of marriage. You should not rely exclusively on the information at this site; it is intended only provide the necessary case filing forms and, in the instance of simplified joint dissolutions, as a general guide for selfrepresentation. Marriage counseling services are available throughout the St. Louis region. If you are eligible to use the joint simplified proceeding, you will lose any right you may have to maintenance (commonly known as alimony). Once you lose the right to maintenance in a legal proceeding, you can never again obtain maintenance from your former spouse. A judgment of dissolution of marriage (divorce) permanently settles all financial rights arising out of your marriage, including the right to property held in the name of your spouse. A judgment entered in a dissolution proceeding is final. You will not be able to appeal from the judgment unless you challenge it within thirty (30) days of entry or unless you file a proper pleading within two (2) years and can prove fraud, duress, or other legally sufficient grounds to set aside a judgment as provided by law.





To learn more about how to prepare a petition and judgment for dissolution of marriage, consult your attorney. If you do not have an attorney, or cannot afford one, information is available from the law library in the basement of the courthouse. If you have children under the age of 18, you are required to enroll in the Children First Program before your judgment can be entered. To sign up for this program, call 618-251-6214. For information about the Children First Program, exit this site and go to "Divorcing Parents of Minors." You may file your petition and all pleadings Monday through Friday, 8:30 am to 4:30 pm, in Room 118 of Circuit Clerk's office (on the first floor of the Madison County Courthouse). When you file your petition, you will be advised when you will have to see a judge again.

** Circuit Clerk employees may answer your general questions, but are prohibited from assisting in preparation of documents **

JOINT SIMPLIFIED DISSOLUTION FOR MARRIAGE General information, instructions and necessary filing forms are provided below for couples who wish to file a joint simplified petition for dissolution of marriage. This joint simplified dissolution procedure is not available to everyone ­ there are several limitations. Read the information below carefully to see if you qualify for a joint simplified dissolution of marriage. If you use this joint simplified proceeding you will lose any right you may have to maintenance (commonly known as alimony). Once you lose the right to maintenance in a legal proceeding, you can never again obtain maintenance from your former spouse.

Who May Use the Joint Simplified Dissolution of Marriage Procedures In order to use the Joint Simplified Dissolution of Marriage procedures, the following must apply to you and your spouse: You must have been married less than eight (8) years and either you or your spouse (or both) must have lived in the State of Illinois for at least ninety (90) days immediately prior to filing for the dissolution. No children were born to or adopted by you and your spouse during your relationship and the wife is not now pregnant. Irreconcilable differences have caused the irretrievable breakdown of your marriage. All efforts at reconciliation have failed and future attempts at reconciliation would not be in the best interest of you and your spouse. You and your spouse must have lived separate and apart for at least six months and you must be willing to waive the requirement for a two-year separation before obtaining a dissolution on the grounds of irreconcilable differences. Your joint annual gross income from all sources must be less than $35,000 and neither party may have a gross annual income in excess of $20,000. Your most recent income tax return is required to show proof of income. The total value of marital property you and your spouse own, less any encumbrances (amounts owed on property, such as a car loan) must be less than $10,000. Neither you nor your spouse may own any real estate. You and your spouse each must be willing to permanently give up any right to maintenance (alimony). You and your spouse must sign a written agreement dividing between yourselves all marital assets worth more than $100 and dividing responsibility for all debts and liabilities. You must divide the property and sign and exchange all documents (for example, automobile titles) necessary to carry out the agreement before any court hearing. You and your spouse must waive any right you may have to a bifurcated hearing on your dissolution petition (that is, a hearing held in two parts, one to decide the issues related to granting the dissolution and another to decide any property or other issues).

Instructions for Completing Forms for Joint Simplified Dissolution of Marriage There are five (5) forms which must be completed for obtaining a joint simplified dissolution of marriage. All of these forms have been drafted to be self-explanatory and as easy to complete as possible. The first three forms listed below (numbers 1-3) must be signed by both spouses in the presence of a Notary Public. A Notary Public is available at the Circuit Clerk's office. Until you have a Notary Public present to attest to your signature in writing, do not sign the Joint Affidavit regarding Separation of the Parties, Division of Property and Waiver of Bifurcated Hearing; Joint Petition for Simplified Dissolution of Marriage; and Agreement as to Assets and Debts.

Forms: 1. Joint Petition for Simplified Dissolution of Marriage 2. Joint Affidavit regarding Separation of the Parties, Division of Property and Waiver of Bifurcated Hearing 3. Agreement as to Assets and Debts 4. Judgment for Dissolution of Marriage 5. Certificate of Dissolution of Marriage (available at the Circuit Clerk's office, once the above four forms have been filed). The above-listed forms appear after this page. You may access the forms by scrolling down, but please read the following before scrolling down. With all five forms, you should either type, or neatly print with black ink, the necessary information. If you complete the forms by hand, be sure your printing is legible, or you may be required to start over and complete the forms again. Fill out all forms completely. Even though this is a "joint" petition, one of the parties must be designated as a "Plaintiff" and the other must be designated as a "Defendant." Traditionally, the party seeking the dissolution is the plaintiff. The Judgment for Dissolution of Marriage need not be signed in front of a Notary, but should be completed and signed by both parties, below the words "Approved as to Form and Content," before your hearing. The judge will complete the "Entered" line and sign the Judgment if the dissolution is granted. If the wife wishes to return to her maiden or former name, she should complete paragraphs 11 and C of the Petition form and paragraphs 11 and D of the Judgment form. You must also complete the Certificate of Dissolution of Marriage and submit it when the judge grants the dissolution, along with a copy of your most recent income tax return. Other than providing this brochure and accompanying forms, employees of the Circuit Clerk are prohibited by law from giving any legal advice.

MATT MELUCCI
Madison County Clerk of Court Edwardsville, IL 62025-1950

IN THE CIRCUIT COURT OF THE THIRD JUDICIAL CIRCUIT Madison County, Illinois
IN RE THE MARRIAGE OF:

Plaintiff; vs.

) ) ) ) ) )

NO.

Defendant.

JOINT PETITION FOR SIMPLIFIED DISSOLUTION OF MARRIAGE
Now comes Plaintiff, , without counsel, and Defendant, , without

counsel, and hereby petition this Honorable Court for a dissolution of the marriage between Plaintiff and Defendant. In support of this petition for dissolution of marriage, the parties state as follows: 1. The Plaintiff is presently _____ years of age; Plaintiff's occupation is , Illinois; and has/ ; Plaintiff resides at has not resided in the State of

Illinois for at least ninety (90) days immediately preceding the filing of this Petition for Dissolution of Marriage. 2. The Defendant is presently _______ years of age; Defendant's occupation is resides at Marriage. 3. The Plaintiff and Defendant have been married for less than eight (8) years prior to the filing of this petition; they were married on (date) . 4. No children were born to the Plaintiff and Defendant during their relationship; no children were adopted by Parties; and (wife's name) 5. , to her knowledge, is not pregnant. ; and the marriage was registered in the County of , State of , Illinois; and ; Defendant has/ has not

resided in the State of Illinois for at least ninety (90) days immediately preceding the filing of this Petition for Dissolution of

The parties have lived separate and apart for a continuous period in excess of six (6) months and irreconcilable differences have caused the irretrievable breakdown of their marriage; efforts at reconciliation have failed and future attempts at reconciliation would be impracticable and not in the best interests of the parties. The parties have signed an affidavit waiving the requirement for a continuous period living separate and apart in excess of two (2) years. The parties have lived separate and apart since (date) . Page 1 of 3

6.

Neither party is dependent on the other party for spousal support (also known as alimony or maintenance), or each party is willing to waive the right to spousal support. Both parties understand that consulting with attorneys may help determine eligibility for spousal support. Both Plaintiff and Defendant waive any rights to maintenance.

7. 8. 9.

Neither Plaintiff nor Defendant has any interest in real property (real estate). The parties have disclosed to each other all assets and their tax returns for all years of the marriage. Neither party has a gross annualized income in excess of $20,000; the Plaintiff's gross annual income from all sources is $ ; the Defendant's gross annual income from all sources is $ ; and the total annual income of the parties is less than $35,000.00.

10. The total fair market value of all marital property, after deducting all encumbrances, is less than $10,000.00 and the parties have executed a written agreement dividing all assets in excess of $100.00 in value and allocating responsibility for debts and liabilities between the parties. A copy of the written agreement, signed by both parties, is filed with this petition. 11. (Optional) WHEREFORE, the parties pray as follows: A. B. That the parties be awarded a Judgment of Dissolution of Marriage dissolving the bonds of matrimony existing between them. That the written agreement of the parties dividing marital assets, debts and liabilities, a copy of which is filed with this petition, be incorporated into the final order and judgment of this Court granting the petition for dissolution of marriage. C. (Optional) That (wife's name) . D. That this Court grant the parties such other and further relief as may be just. be restored to her former/maiden name, `s former/maiden name was .

___________________________________________ Plaintiff (signature)

Defendant (signature)

Page 2 of 3

Case No

VERIFICATION ­ JOINT PETITION

STATE OF ILLINOIS COUNTY OF MADISON

) ) SS )

, Plaintiff, being first duly sworn upon oath, depose and say that I have read the foregoing Joint Petition for Simplified Dissolution of Marriage, understand the contents thereof, and believe the same to be true and correct to the best of may knowledge and belief.

Plaintiff (signature)

Subscribed and sworn before me, a Notary Public, this _______ day of

, 200

.

NOTARY PUBLIC _______________________________________________________

STATE OF ILLINOIS COUNTY OF MADISON

) ) SS )

, Defendant, being first duly sworn upon oath, depose and say that I have read the foregoing Joint Petition for Simplified Dissolution of Marriage, understand the contents thereof, and believe the same to be true and correct to the best of may knowledge and belief.

Defendant (signature)

Subscribed and sworn before me, a Notary Public, this _______ day of

, 200

.

NOTARY PUBLIC
Page 3 of 3

Case No

MATT MELUCCI Madison County Clerk of Court Edwardsville, IL 62025-1950 IN THE CIRCUIT COURT OF THE THIRD JUDICIAL CIRCUIT Madison County, Illinois
IN RE THE MARRIAGE OF:

Plaintiff; vs.

) ) ) ) ) )

NO.

Defendant.

JOINT AFFIDAVIT REGARDING SEPARATION OF THE PARTIES, DIVISION OF PROPERTY AND WAIVER OF BIFURCATED HEARING

NOW COME

, Plaintiff, and

, Defendant, and being

first sworn on their oaths, depose and state as follows:

1. 2. 3. 4.

That irreconcilable differences have caused the irretrievable breakdown of their marriage. That all efforts at reconciliation of the differences between the parties have heretofore failed and future attempts at reconciliation would be impracticable and not in the best interest of the parties. That the parties have lived separate and apart for a continuous period of more than six (6) months prior to the date of this affidavit, having separated on or about a. and having remained living separate for all times thereafter. That each of the parties hereto expressly waive the requirement that the continuous period of living separate and apart be in excess of two (2) years in order for the Court to enter a Dissolution of Marriage based upon irreconcilable differences which have caused the irretrievable breakdown of their marriage; and, b. Each of the parties further stipulates that the requirement shall be reduced to a period only in excess of six (6) months rather than in excess of two (2) years as provided by Section 401 (a) (2) of the Illinois Marriage and Dissolution of Marriage Act.

5.

That the marital property belonging to the parties has been divided according to the terms of the written agreement of the parties filed with the Petition for Dissolution of Marriage in this cause, and that the parties have executed all documents required to carry out the agreement. That the parties waive any right either may have to a bifurcated hearing in this cause. That each of the parties represents that their signing of this Affidavit is their individual, sole, and voluntary act.

6. 7.

Plaintiff (signature)

Defendant (signature)

Page 1 of 2

Case No

VERIFICATION ­ JOINT AFFIDAVIT

STATE OF ILLINOIS COUNTY OF MADISON

) ) SS )

, Plaintiff, being first duly sworn upon oath, depose and say that I have read the foregoing Joint Affidavit, understand the contents thereof, and believe the same to be true and correct to the best of may knowledge and belief.

Plaintiff (signature)

Subscribed and sworn before me, a Notary Public, this _______ day of

, 200

.

NOTARY PUBLIC

_______________________________________________________

STATE OF ILLINOIS COUNTY OF MADISON

) ) SS )

, Defendant, being first duly sworn upon oath, depose and say that I have read the foregoing Joint Affidavit, understand the contents thereof, and believe the same to be true and correct to the best of may knowledge and belief.

Defendant (signature)

Subscribed and sworn before me, a Notary Public, this _______ day of

, 200

.

NOTARY PUBLIC
Page 2 of 2

Case No

MATT MELUCCI Madison County Clerk of Court Edwardsville, IL 62025-1950 IN THE CIRCUIT COURT OF THE THIRD JUDICIAL CIRCUIT Madison County, Illinois
IN RE THE MARRIAGE OF:

Plaintiff; vs.

) ) ) ) ) )

NO.

Defendant.

JUDGMENT FOR DISSOLUTION OF MARRIAGE
This cause having come on for hearing on the Joint Petition for Simplified Dissolution of Marriage filed by the parties hereto; the Court having examined and considered the Petition, the Affidavit of the parties, and all other pleadings and exhibits filed in this matter; the Court having heard the testimony presented herein; and the Court being otherwise fully advised in the premises, find as follows: 1. 2. 3. This Court has Jurisdiction over the subject matter and the parties hereto. and/or (Plaintiff and/or defendant, or both) now, and for ninety (90) days continuously and immediately preceding this date, have been residents of the State of Illinois. The parties have been married for less than eight (8) years prior to the filing of this petition; the parties were married on (mo/day/year) ; and the marriage was registered in County, State of . The parties have lived separate and apart for a continuous period in excess of six (6) months; irreconcilable differences have caused the irretrievable breakdown of the marriage; efforts at reconciliation have failed; and, further efforts at reconciliation would not be in the best interests of the parties. The parties have each signed an affidavit waiving the requirement for a continuous period living separate and apart in excess of two (2) years. The parties have each signed a waiver of any right to a bifurcated hearing in this case. No children were born to or adopted by the parties during their relationship and to the best of her knowledge is not pregnant at this time.
(wife's name)

4.

5. 6. 7.

8. 9.

Both the Plaintiff and Defendant have waived any right to maintenance. Neither Plaintiff nor Defendant has any interest in real property. The parties have disclosed to each other all assets and their tax returns for all years of marriage. Neither party has a gross annualized income in excess of $20,000, and the total annualized income of the parties is less than $35,000.

10. The total fair market value of all marital property owned by the parties, after deducting all encumbrances, is less than $10,000.00. The parties have executed a written agreement, which the Court finds is not unconscionable, dividing all assets in excess of $100.00 in value and allocating responsibility for all debts and liabilities between the parties. A copy of the written agreement, signed by both parties, was filed with the petition in this cause and is hereby incorporated by reference as if fully set forth herein.
Page 1 of 2

11. (Optional)
(wife's name)

`s former/maiden name was

.
(wife's maiden OR former name)

WHEREFORE, IT IS HEREBY ORDERED, ADJUDGED AND DECREED: A. B. The present marriage between the parties is hereby dissolved, and Plaintiff and Defendant are each hereby awarded a Judgment of Dissolution of Marriage dissolving their present bonds of matrimony. This Court adopts as a part of this Judgment, as if it were fully set forth herein, the agreement of the parties concerning the distribution of assets, debts and liabilities. Plaintiff and Defendant each is hereby ordered to dispose of all claims each may have against the other, and to dispose of all assets, debts and liabilities, in accordance with and pursuant to the agreement entered into by the parties and presented to this Court. Plaintiff and Defendant are each ordered to timely execute any and all titles, certificates and other documents of any kind or nature whatsoever, necessary to carry out the terms and condition of this Judgment of Dissolution of Marriage as to the division of assets, debts and liabilities ordered herein. Each of the parties is hereby denied maintenance for now and for all times hereafter. (Optional)
(wife's name)

C. D. E.

is hereby restored to her former/maiden name,

.

Except for the provisions contained in this Judgment of Dissolution of Marriage, each of the parties is hereby barred and foreclosed from making any and all claims against the other whether for alimony or maintenance, homestead rights, dower rights, rights of inheritance or any and all other property rights, whether real, personal or mixed, which either of them may now have or may hereafter acquire arising out of the marital relationship heretofore existing between them. This Court retains jurisdiction of this cause for the purpose of enforcing the provisions of this Judgment of Dissolution of Marriage.

F.

ENTERED: JUDGE APPROVED AS TO FORM AND CONTENT:

Plaintiff (signature)

Defendant (signature)

Page 2 of 2

Case No

MATT MELUCCI Madison County Clerk of Court Edwardsville, IL 62025-1950 IN THE CIRCUIT COURT OF THE THIRD JUDICIAL CIRCUIT Madison County, Illinois
IN RE THE MARRIAGE OF:

Plaintiff; vs.

) ) ) ) ) )

NO.

Defendant.

AGREEMENT AS TO ASSETS AND DEBTS
Now come
(Plaintiff's Name)

, Plaintiff, and
(Defendant's Name)

, Defendant,

and hereby agree to the following distribution of all marital assets in excess of One Hundred Dollars ($100.00) in value and the following division of all marital debts and liabilities.

Marital Assets
Description of Asset and Estimated Value
(List all marital assets in excess of One Hundred Dollars [$100] in value ­ assets of lower value may be listed)

Party to Receive Asset
(Enter name of Party [Husband or Wife] who will receive asset)

1. 2. 3. 4. 5. 6. 7. 8. 9. 11. 12. 13. 14. 15.
Page 1 of 2

Marital Debts and Liabilities
Description of Debt or Liability
(List all Marital Debts and Liabilities)

Amount
(list total balance due)

Account Number
(List Account Number where applicable)

Party to Pay Debt
(Enter name of Party [husband or wife] who will be responsible paying the debt or liability)

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

Plaintiff's Signature
Subscribed and Sworn before me this __________ day of , 200 .

Defendant's Signature
Subscribed and Sworn before me this __________ day of , 200 .

Notary Public

Notary Public

(Seal)

(Seal)

Page 2 of 2

Case No

AFFIDAVIT AS TO MILITARY SERVICE

(Petitioner) vs Case Number (Respondent) AFFIDAVIT AS TO MILITARY SERVICE OF RESPONDENT I, 1. My age is , make oath and say as follows: years, my residence is at . 2. I am the petitioner in the above-entitled action and as such have full knowledge of the facts relating thereto. (Check A., B. or C.) A. Said respondent is in the military service of the United States. B. Said respondent is not in the military service of the United States. C. I am not able to determine whether or not respondent is in such service. D. I further state that and my occupation is

(In D., set forth the fact upon which affidavit is based. The Soldiers and Sailors Civil Relief Act requires facts be stated showing respondent is not in the military service. Stating conclusion only is not sufficient. If respondent is in the military service, file date of induction, unit, and length of service, if known.)

(Petitioner)

SUBSCRIBED AND SWORN TO ME THIS 200 .

DAY OF

, A.D.,

NOTARY PUBLIC

ENTRY OF APPEARANCE ­ WAIVER AND CONSENT STATE OF ILLINOIS COUNTY OF MADISON IN RE THE MARRIAGE OF: ) ) )

SS.

IN THE CIRCUIT COURT

CASE NUMBER PETITIONER
AND

RESPONDENT I HEREBY ENTER MY APPEARANCE IN THE ABOVE-ENTITLED CAUSE AS RESPONDENT HEREIN, AND EXPRESSLY WAIVE THE NECESSITY OF PROCESS OF SUMMONS AND CONSENT THAT THE SAME PROCEEDINGS MAY BE HAD HEREIN, AS FULLY AND WITH THE SAME FORCE AND EFFECT AS THOUGH I HAD BEEN DULY AND REGULARLY SERVED WITH PROCESS OF SUMMONS THEREIN IN THE STATE OF ILLINOIS, AT LEAST THIRTY DAYS PRIOR TO ANY RETURN DAY DESIGNATED BY THE PETITIONER HEREIN OR AS PROVIDED BY LAW. I FURTHER CONSENT THAT IMMEDIATE DEFAULT MAY BE TAKEN AND ENTERED HEREIN AGAINST ME UPON THE FILING OF
THIS APPEARANCE OR AT ANY TIME THEREAFTER AND THAT AN IMMEDIATE HEARING OF SAID CAUSE MAY BE HAD WITHOUT FURTHER NOTICE.

DATED AT

, ILLINOIS THIS

DAY OF

, A.D.,200

.

STATE OF ILLINOIS

) ) COUNTY OF MADISON )

SS.

I, A NOTARY PUBLIC IN AND FOR SAID COUNTY IN THE STATE AFORESAID, DO HEREBY CERTIFY THAT PERSONALLY KNOWN TO ME TO BE THE SAME PERSON WHOSE NAME IS SUBSCRIBED TO THE WITHIN INSTRUMENT OF WRITING, APPEARED BEFORE ME THIS DAY IN PERSON, AND ACKNOWLEDGED THAT SIGNED THE SAME AS FREE AND VOLUNTARY ACT, FOR THE USES AND PURPOSES THEREIN SET FORTH. GIVEN UNDER MY HAND AND NOTARIAL SEAL, THIS 200 .
DAY OF

, A.D.,

NOTARY PUBLIC
Case No

Instructions for Affidavit & Application To Sue or Defend as an Indigent Person
If you claim you are not financially able to pay filing fees and costs, you may apply to the Court for waiver of those charges as an indigent person. To seek waiver of those fees, you must complete and submit the form "Affidavit & Application to Sue or Defend as an Indigent Person." Please submit the completed form as soon as possible so that the Judge can rule on your request, and you can provide further information if required. You must PRINT all of the information required on the form and sign your signature affirming under penalty of perjury that the information you have given is truthful. Complete all parts of the form. The Judge will review your completed application and either grant or deny it or require additional information. If you are being sued and the Court denies the application, you will have to pay the filing fees before the answer date or extension. If you do not, a default Judgment may be entered against you. In order to qualify as indigent, the Court uses income guidelines based on those established by U.S. Department of Health and Human Services:

2008 GUIDELINES ­ INDIGENT PARTY
(125% of Health & Human Services Poverty Level)

SIZE OF FAMILY 1 2 3 4 5 6 7 8

YEARLY $13,000 $17,500 $22,000 $26,000 $31,000 $35,000 $40,000 $44,400

MONTHLY $1,083 $1,458 $1,833 $2,208 $2,583 $2,958 $3,333 $3,708

For family units with more than 8 members, add $4,350 yearly or $363 monthly for each additional person.

IN THE CIRCUIT COURT FOR THE THIRD JUDICIAL CIRCUIT MADISON COUNTY, ILLINOIS _________________________________________, Plaintiff vs. _________________________________________, Defendant

Case No. __________________

AFFIDAVIT AND APPLICATION TO SUE OR DEFEND AS AN INDIGENT PERSON The undersigned as affiant, under penalty of perjury as provided in Section 735 ILCS 5/1-109, certifies that the statements in this instrument are true and correct, or made on information and belief and believed to be true: 1.) I am familiar with the facts stated herein and this Application to Sue or Defend as an Indigent Person is brought for: myself as Applicant on behalf of a minor or a disabled adult, ________________________________. 2.) The applicant is named as a defendant in a pending action or intends to file a lawsuit. 3.) The applicant receives assistance from the following benefit programs: SSI, AABD, TANF, Food Stamps, General Assistance, State Transitional Assistance, State Children & Family Assistance. (Circle all benefits received.) 4.) The applicant's household income is 125% or less of the current poverty level as established by the United States Department of Health and Human Services.
(Clerk will provide current chart to make this determination.) (You must also provide the following information to confirm your eligibility.)

Number of persons in applicant's household ________ Household income: $_____________ monthly. The applicant's household income includes Social Security Disability Payments. Unemployment compensation benefits. 5.) The applicant is unable to proceed in an action without payment of fees, costs, and charges and the applicant's payment of those fees, costs, and charges would result in substantial hardship to the applicant or the applicant's family. 6.) Applicant is: unemployed, or $ ____________ monthly. 7.) Applicant is married, or $____________ monthly. 8.) Applicant is receiving employed, and the applicant's current income is

unmarried. The applicant's spouse's current income is paying child support in the amount of $___________ monthly.

9.) The applicant has the following assets: money in banks, credit unions and savings & loans, in the amount of $__________ real estate with equity of $_____________ located at ____________________________ automobiles with equity of $ _____________
(Equity is the value of the property minus any mortgage or debt.)

other financial assets, including retirement accounts, of $___________ other assets____________________________________ in the amount of $___________ 10.) The applicant's total monthly living expenses are $______________ as follows:
(Do not include payments for debts or child support.)

Rent or mortgage payment: ___________ Food: ___________ Clothing: _________ Car payment: _________ Car insurance:_________ Gasoline & maintenance: _________ Utilities: _____________ Telephone: ____________ Child care: _____________ Medical, hospital & prescription: _______________ Insurance: _______________ Other: _____________________________________________________________________ 11.) The affiant, in good faith, believes that the applicant has a meritorious claim or defense. Wherefore, the Affiant seeks permission of this Court for the Applicant to sue or defend as an indigent person.

Affiant ORDER Having reviewed the Application to Sue or Defend as an Indigent Person, the Court now enters its Order: Application ALLOWED. The applicant is allowed to sue or defend as a poor person without payment of fees, costs or charges. Assessment against any other party is reserved pending outcome. Application DENIED for the following reason(s): Applicant is not indigent. Other: ________________________________________________ ________________________________. Applicant granted _____ days to pay filing fees. Application is INCOMPLETE. Default Judgment may be entered if application is not completed by the answer date or extension. Applicant granted _____ day extension to submit completed application. RULING RESERVED. Applicant MUST submit most recent Federal income tax return along with yearto-date paycheck stub or statement within _____ days. Failure to do so may result in entry of Default Judgment. __________________________ Date __________________________________________ Presiding Judge

Clerk to mail copies of this Application and Order to all parties of record. Rev. 3-2-04

Case No