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IN THE CIRCUIT COURT OF THE ELEVENTH JUDICIAL CIRCUIT McLEAN COUNTY, ILLINOIS Plaintiff, 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 make the following statement in support of my request to waive or defer payment of court costs. 1. Name Date of Birth Telephone No. ( ) 2. Address City State Zip 3. Family: Marital Status Number of children 4. Name and address of employer Length of employment Occupation 5. INCOME: $ per month from employment $ per month from pension, trust, annuity, welfare, Workman’s Compensation, retirement or disability plan, or a similar State, Federal, local or private benefit plan, or student loans or grants $ Total per month from all sources $ Total gross income for preceding calendar year 6. ASSETS: $ Home or other dwelling Where situated $ Cars $ Bank accounts $ Cash on hand $ Total value of assets 7. LIABILITIES: Mortgage/rent on residence $ payment $ Amount owed on car $ payment $ Personal debts $ To whom owed Other debts $ To whom owed Total liabilities and debts $ Total payments $ 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 he verily believes the same to be true. DATED: Plaintiff/Defendant PETITION: GRANTED DENIED DATED: JUDGE: