P1-Ci-013-E- Kane County Judicial Circuit - Application For Waiver Of Court Fees
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3IN THE CIRCUIT COURT OF THE SIXTEENTH JUDICIAL CIRCUIT
KANE COUNTY, ILLINOIS
Case No.
Plaintiff/Petitioner
Defendant/Respondent
File Stamp
Enter the name of the person who started the lawsuit
Enter the name of the person being sued as
Enter the Case Number given by the Circuit Clerk or
as Plaintiff/Petitioner.
Defendant/Respondent.
leave this blank if you do not have one.
APPLICATION FOR WAIVER OF COURT FEES
In 1a., enter your
Pursuant to Illinois Supreme Court Rule 298 and 735 ILCS 5/5-105, I state:
full name. If you
are completing
1.
I am providing the following information about myself:
this form on
behalf of a
a. Name:
minor or an
First
Middle
Last
incompetent
adult, provide
b. Year of Birth:
that person's
information.
c. Street Address:
In 1b., only enter
the year you were
City, State, Zip:
born.
d. I believe I cannot afford to pay the court fees in this case.
DO NOT enter
your entire date
of birth.
2. I am providing the following information about people who live with me:
In 1c., enter your
complete current
a. I support
adults (not counting myself) who live with me.
address.
b. I support
children under 18 who live with me.
In 2a., enter the
number of people
age 18 and older
3. I have received 1 or more of the benefits listed below in the past 4 weeks:
living in your
house who you
Yes
No
support. Support
means that the
Supplemental Security Income (SSI) (Not Social Security)
people rely on
you financially.
Aid to the Aged, Blind and Disabled (AABD)
In 2b., enter the
Temporary Assistance to Needy Families (TANF)
number of people
under age 18
State Children & Family Assistance
living in your
house who you
Food Stamps (SNAP)
support.
General Assistance (GA)
In 3., check
"Yes" if you have
Transitional Assistance
received at least 1
of the benefits
listed in the past
4 weeks.
**If you answered "Yes" in section 3, skip section 4 and sign the form.**
If you check
"Yes" in 3, skip 4
and sign the
form.
Original - Clerk
Copy - Party
Copy - Party
P1-CI-013 (02/15) Page 1 of 3
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