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Application To Sue As A Poor Person (Illinois)

This form is a supplement to the Legal Separation packet in Illinois. The form provided here is simply a sample of what the actual form looks like.

STATE OF ILLINOIS

IN THE CIRCUIT COURT OF THE ___________ JUDICIAL CIRCUIT

__________________ COUNTY

) _____Application granted
) _____Application denied
No. _______
__________________, 20____
________________________
JUDGE

______________________)
Plaintiff,)
vs. )
______________________)
Defendant. )


APPLICATION TO SUE AS A POOR PERSON

I, _____________________________________, on my own behalf, on oath state:

1. My current address is _________________________

_________________________

2. My occupation, source of income, amount of public benefits is

_________________________

_________________________

3. My other sources of income or support are _________________________

4. My income for the preceding year was approximately ________________________.

5. The sources and amounts of income I expect to receive in the future are:

_________________________

6. Person(s) who are dependent on me for support are: _________________________

_________________________

7. I own no real estate. The total value of all my personal property does not exceed

$___________ in value and consists of clothing and furniture, and other household items,

including a 20____, ____________ motor vehicle, valued at $____________.

8. I filed no applications for leave to sue or defend as a poor person during the preceding year, and none were filed on my behalf.

9. I am unable to pay the costs of commencing and prosecuting this action.

10. I have a meritorious claim.

WHEREFORE, Applicant prays the Court to permit her/him to commence and prosecute this action as a poor person under 735 ILCS 5/5-105 of the Code of Civil Procedure.

___________________________________
Plaintiff

Under penalties as provided by law pursuant to Section 5/1-109 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/she verily believes the same to be true.

___________________________________
Plaintiff


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INSTRUCTIONS FOR FILLING OUT THIS FORM
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FORM: Application to Sue as a Poor Person

Introduction: Your name

Paragraph 1: Your address, include street and city.

Paragraph 2: The amount and source of your income, for example, $339.00 per month in AFDC, supplemented by Food Stamps.

Paragraph 3: List other sources of income not listed in 2.

Paragraph 4: The amount of income you had in the last year.

Paragraph 5: Should be the same as 2, unless you expect your income to go up or down, in which case you should list what you expect your income to be.

Paragraph 6: List the names and birthdates of your children and/or others you support financially.

Paragraph 7: First blank: total value of your possessions; Second blank: year and make of your car; if you do not have a car, simply put "none"; Third blank: value of your car.

Sign your name on both blank lines above where it says "Plaintiff" and print your name below each signature.

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