Application For Waiver Of Court Fees Template - Circuit Court Of Illinois Page 2
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2ASSETS
9. I own the following:
House _______________________________________________ (Address) __________________________ (Value)
Car/Truck ____________________________________________ (Year/type) _________________________ (Value)
Motorcycle ___________________________________________ (Year/ type) ________________________ (Value)
Recreational Vehicle ___________________________________ ( Year/type) _________________________ (Value)
I have _________________ in a savings account.
I have _____________________ in a checking account.
I have other income in the sum of ________________ from _________________________________ (source of income)
The following things affect my ability to pay costs (disabilities, health problems, etc.): ________________________________
________________________________________________________________________________________________________________
AFFIDAVIT
Applicant, after being duly sworn and upon penalty of perjury, hereby certifies that the statements set forth in this application are
true and correct.
________________________________________________
Applicant
SUBSCRIBED AND SWORN TO before me this ___________day of ____________________, 20____.
________________________________________________
Circuit Clerk/Notary
ORDER
Application set for hearing on ____________________, Courtroom ______________. Clerk to give notice to Applicant.
(Date/time)
_______________________________________________
____________________________________________
Judge
(Date entered)
APPLICATION APPROVED
Application approved on ___________________ (date). Clerk to give notice to Applicant.
Applicant to pay fees, costs and charges out of any judgment or settlement received.
_______________________________________________
___________________________________________
Judge
(Date entered)
APPLICATION DENIED
Application denied on _____________________ (date). Clerk to give notice to Applicant
Specific reason __________________________________________________________
Payment of costs, fees and charges in the sum of ________________ deferred until _________________________(date).
If not paid by said date, cause dismissed.
For good cause shown, Applicant to make installment payments on said costs in the sum of ___________________
weekly
bi-weekly
monthly commencing on __________________________ and a like amount each
week
two weeks
month until total costs, fees and charges in the sum of ________________ are paid in full
_______________________________________________
___________________________________________
Judge
(Date entered)
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