Free STATE OF ILLINOIS - Illinois

STATE OF ILLINOIS IN THE CIRCUIT COURT OF THE 14TH JUDICIAL CIRCUIT ROCK ISLAND COUNTY
ORDER _________________________________
PLAINTIFF/PETITIONER

APPLICATION GRANTED APPLICATION DENIED

VS.

No.__________________ __________________________________________________ __________________________________________________ __________________________________________________ _________________________________________________ JUDGE

_________________________________ DEFENDANT/RESPONDENT

APPLICATION AND AFFIDAVIT TO SUE OR DEFEND AS AN INDIGENT PERSON
I, __________________________________, the On my own behalf, OR as A(n) Minor OR Parent, Plaintiff/Petitioner Defendant/Respondent herein, age______,

Guardian,

Other_______________on behalf of ________________, I, or the person on whose

Incompetent Adult, state and believe in good faith that claim/ defense.

behalf this petition is brought, have a meritorious I have knowledge of the facts stated herein.

1. I am employed as a(n)___________________________________. Yearly gross salary $______________________
(before taxes)

Name of employer:_____________________________________________________________________________ Address of employer:____________________________________________________________________________ Last employer:_________________________________________________________________________________ I began receiving Unemployment Compensation on ____/____/____ in the amount of $_________(per month). 2. My spouse is employed as a(n)______________________________. Yearly gross salary $____________________
(before taxes)

Name of employer:_____________________________________________________________________________ Address of employer:___________________________________________________________________________ My spouse is unemployed as of ____/____/____. Last employer:________________________________________________________________________________ My spouse began receiving Unemployment Compensation on ___/___/___ in the amount of $_________per month. 3. My other sources of income are: Foster Care SSI Public Aid Child Support Food Stamps Family Assist General Assist

Aid to the Aged, Blind and Disabled

Temp Assist for Needy Families

State Transitional Assist

State Children and Family Assist

Other:_______________ $_______per month

5. The nature and value of property I own includes: and mortgage and liens outstanding)

Real Estate (Describe property, specify address, present value

_____________________________________________________________________________________________ Cash, bank accounts, etc. $_________ Household goods $_______________ 6. Clothing and Jewelry $________ Furniture, appliances,

Automobile-Model___________ Year_________ Value $_______

The names and ages of persons dependent on the application for support are: _______________________/______________________/______________________/______________________ _______________________/______________________/______________________/______________________

7. 8. 9. 10.

I am paying child support in the amount of $______________________per__________________. I am paying spousal support in the amount of $____________________per__________________. My monthly living expenses (not including payment of debts and child support) are $_________________. I am unable to pay the costs of this case, and to do so would cause a substantial hardship to me and my family.

Name:_____________________________________________ Address:___________________________________________ City/State/Zip:______________________________________ Telephone:_________________________________________ Date:________________________________,_________________
Under penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, the undersigned certifies that the statements set forth in this instrument are true and correct, except as to matters therein stated to be on information and belief and as to such matters the undersigned certifies as aforesaid that s/he verily believes the same to be true.

____________________________________ Signature of Applicant

Lisa Bierman, Clerk of the Circuit Court of Rock Island County, Illinois

Revised 8/05

735 ILCS 5/5-105.5 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; appearance 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 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 will 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. (735 ILCS 5/5-105.5) (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).

LISA BIERMAN, CLERK OF THE CIRCUIT COURT OF ROCK ISLAND COUNTY, ILLINOIS

Revised 12-05