Free CCG0041 - Illinois

(Rev. 1/2/01) CCG 0041 A IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS PEOPLE OF THE STATE OF ILLINOIS

v.

______________________________________________

}

No. _____________________________ No. ______________________________ No. _____________________________

AFFIDAVIT OF ASSETS AND LIABILITIES
I, _________________________________________ defendant in this case, on oath state that I am without adequate assets to retain counsel, and that I make the following statement in support of my request to be represented by courtappointed counsel. 1. Name ____________________________________________ Date of Birth _______________________ 2. Address _________________________________________ Phone _________________________ 3. Family: (a) Marital Status _______ (b) Number of Children _______ (c) Number of other Dependents ______ and relationship ______________________________________________________________________

_________________________________________________________________________________ 4. Name and address of employer _____________________________________________________________ Length of employment ___________________ Occupation ____________________________________
5. Earnings and sources of income: (a) $ ______________________ per month from employment. (b) $ _______________________ per month from pension, trusts, annuity, welfare, Workers' Compensation, retirement or disability plan or any similar State, Federal, Local or private benefit plan. (c) $ _______________________ per month from rents, royalties, bonds, securities, or interest. (d) $ ________________________ per month from other sources enumerated herein _________________

____________________________________________________________________________. (e) $ _______________________ per month from all sources.
6. Value of assets: (a) Home or other dwellings $ _____________________________________________________________ (b) Other real property $ _______________________ Where situated ___________________________ (c) Car $ ________________________ Make ________________________________ Year __________ (d) Other personal property (jewelry, household contents, furs, etc.) $ ____________________________ (e) Bank Accounts $ __________________________________________________________________ (f) Cash on hand $ ___________________________________________________________________ (g) Surrender value of life or annuity insurance policies $ _______________________________________ (h) Securities, trusts, bonds $ ____________________________________________________________ (i) Other assets $ _____________________________ Described herein ____________________________ (j) Total value of assets $ _________________________________________________________________ (OVER) DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS

(Rev. 1/2/01) CCG 0041 B 7. Liabilities: (a) Mortgage on home $ _________________________ Monthly payment $ __________________________ (b) Amount owed on car $ ________________________________________________________________ (c) Personal debts $ _______________________ To whom owed _________________________________ (d) Other debts $ _________________________ To whom owed ________________________________ (e) Total liabilities and debts $ ___________________________________________________________ 8. If released on bail, specify amount of security $ ____________________________ and source or payment of security (defendant's funds, borrowed cash, etc.) ______________________________________________

________________________________________________________________________________ ______________________________________
Defendant

Subscribed and sworn to before me

_________________________________, _______ _______________________________________
Deputy Clerk

****************************************************************

ORDER
It is ordered that the Public Defender is appointed as counsel to represent the defendant.

Date: ______________________________

ENTER: ____________________________________ Judge Judge's No. Branch: ____________________________

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