Free IN THE CIRCUIT COURT FOR THE THIRD JUDICIAL CIRCUIT CLERK - Illinois

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." The form follows this page (scroll down). 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 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.

Page 1 of 2

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

Page 2 of 2

Case No.