Application For Waiver Of Court Fees Template - Circuit Court Of Illinois
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1
2CIRCUIT COURT OF ILLINOIS
TH
20
JUDICIAL CIRCUIT
ST. CLAIR COUNTY
______________________________________
Plaintiff
VS
Case No. _______________________
[File stamp]
______________________________________
Defendant
APPLICATION FOR WAIVER OF COURT FEES
Applicant, ______________________________, respectfully requests the court to grant him/her leave to
sue
defend as an indigent person and in support thereof states, under oat, the following facts are true:
I am the
plaintiff
defendant in the above captioned legal proceedings.
I believe, in good faith, I have a meritorious claim/defense.
I am an indigent as defined by 735 ILCS 5/5-105 and unable to
prosecute
defend this action and am unable to pay the
costs, fees and charges herein because:
1.
I am receiving assistance under one or more of the following public benefits programs:
Supplemental Security Income (SSI),
Aid to the Aged, Blind and Disabled (AABD),
Temporary Assistance of Needy Families (TANF),
Food Stamps,
General assistance,
State Transitional Assistance, or
State Children and Family Assistance, or
2.
My family unit contains ____ people (including myself) and the total available income of the family is 125% or less of the current
poverty level as established by the United States Department of Health and Human Services, or
3.
I am being represented by legal aid or other civil legal services provider as defined in 735 ILCS 5/5-105.5, or
4.
I am unable to proceed in this action without payment of fees, costs and charges and the payment of said fees, costs, and charges would
result in substantial hardship to me and/or my family.
EMPLOYMENT
5.
I am not employed.
I am employed by _________________________ and my take-home pay is ____________________
weekly
bi-weekly
monthly.
My spouse is living with me and is not employed.
My spouse is living with me, is employed by _______________________________ and has take-home pay of ____________
weekly
bi-weekly
monthly (including all wages, tips and overtime).
CHILD SUPPORT
6. I am
receiving
paying child support in the sum of _______________
weekly
bi-weekly
monthly.
Child support
is not in arrears
is in areas in the sum of _____________________.
DEBTS
Monthly Payment
7.
I owe the following debts:
TO:______________________________________ in the sum of _________________________ ________________
______________________________________ in the sum of _________________________ ________________
______________________________________ in the sum of _________________________ ________________
TOTAL
_________________________ ________________
LIVING EXPENSES
8. My MONTHLY living expenses (excluding payment of debts and child support) for me and my family are ____________________.
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