P1-Ci-013-E- Kane County Judicial Circuit - Application For Waiver Of Court Fees Page 3
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3(Application for Waiver of Court Fees continued)
Case No.
e. I have the belongings listed below. This includes the belongings of the people I support
In 4e., check all
of the items
who live with me.
owned by you
(check all that apply)
and list the value
Bank accounts and cash totaling:
$
of each item.
Include the items
owned by the
Home real estate, worth:
$
people you
support who live
The total I owe on my home mortgage is:
$
with you.
If you own real
Other real estate, not including the house I live in, worth:
$
estate, include
the total you owe
The total I owe on my other mortgage is:
$
on any mortgage..
1st vehicle worth:
$
The 1st vehicle is paid off:
Yes
No
2nd vehicle worth:
$
The 2nd vehicle is paid off:
Yes
No
Other
:
$
(list items and value)
None of the above
I certify that everything above is true and correct to the best of my knowledge.
Under the Code
of Civil
Procedure, 735
I understand that making a false statement in this form could be perjury.
ILCS 5/1-109,
making a
statement on this
form that you
Your Signature
Street Address
know to be false
is perjury, a Class
3 Felony.
Print Your Current Name
City, State, Zip
The person who
filled out this
form must sign it.
Relationship to Minor or Incompetent Adult (if applicable)
Telephone
Enter the
complete current
address and
telephone number
of the person who
filled out this
form.
If you are filling
out this form for
a minor or an
incompetent
adult, state your
relationship.
Original - Clerk
Copy - Party
Copy - Party
P1-CI-013 (02/15) Page 3 of 3
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