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IN THE CIRCUIT COURT OF THE ELEVENTH JUDICIAL CIRCUIT McLEAN COUNTY, ILLINOIS Plaintiff, v. Case No. Defendant. PETITION/AFFIDAVIT FOR LEAVE TO SUE/DEFEND AS A POOR PERSON I, Plaintiff/Defendant in this case, state that I am without adequate means to advance payment of court costs, and that I make the following statement in support of my request to waive or defer payment of court costs. Name Date of Telephone No. State Zip Family: Marital Status: M S D W Number of Children you are legally obligated to support Name and Address of Length of Employment Occupation Full time or part time? Hours worked per Do you have another If yes, 1. INCOME: a. per month from employment. b. per month from pension, trusts, annuity, Workman’s Compensation, retirement or disability plan, or any similar State, Federal, local or private benefit plan. c. per month from federal, state, or local assistance/subsidy d. If you are married, does your spouse work? Where? Spouse’s income e. total per month from all sources 2. VALUE OF ASSETS: a. Home or other dwelling Where situated b. Cars or other vehicles c. Bank Accounts: Checking Savings d. Cash on hand e. Total value of assets 3. LIABILITIES: a. Mortgage/rent on residence payment b. Amount owed on cars or other vehicles payment(s) c. Personal debts To whom d. Other debts To whom owed e. Total liabilities and debts Total payments 4. Amount of cash bail posted if any, in this or any other pending cases Source of payment: self borrowed funds other CERTIFICATION: Under penalties as provided by law pursuant to 735 ILCS 5/1‐109, 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 he/she verily believes the same to be true. Plaintiff/Defendant Date ORDER: The Petition for Leave to Sue/Defend as a Poor Person is: GRANTED DENIED Date Judge