Citation To Discover Assets - Stephenson County Illinois Circuit Court Page 3
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4INCOME AND ASSET FORM
To judgment Debtor: Please complete this form and bring it with you to the hearing referenced in the enclosed citation notice.
You should also bring to the hearing any documents you have to support the information you provide in this form, such as pay
stubs and account statements. The information you provide will help the court determine whether you have any property or
income that can be used to satisfy the judgment entered against you in this matter. The information you provide must be accurate
to the best of your knowledge.
IF YOU FAIL TO APPEAR AT THIS HEARING, YOU COULD BE HELD IN CONTEMPT OF COURT AND POSSIBLY
ARRESTED.
In answer to the citation and supplemental proceedings served upon the judgment debtor, he or she answers as follows:
Name: __________________________________________Home Phone Number:______________________________________
Home Address: ___________________________________________________________________________________________
Date of Birth:___________________ Marital Status: ___________________ I have ______________dependents.
Do you have a job?
YES
NO
Company’s name I work for: ________________________________________________________________________________
Company’s Address: ______________________________________________________________________________________
JOB:
I earn $_____________ per _________________
If self employed, list here your business name and address: ________________________________________________________
Income from self employment is $______________ per year.
I have the following benefits with my employer: ________________________________________________________________
I do not have a job, but I support myself through:
Government Assistance $ _____________________ per month.
SSI $ ____________________________________ per month
Unemployment $ ____________________________ per month
Pension $ _________________________________ per month
Social Security $ ____________________________ per month
Other $ ___________________________________ per month
REAL ESTATE:
Do you own any real estate?
YES
NO
I own real estate at _______________________________________________________________________________________.
with names of other owners _________________________________________________________________________________
Additional real estate I own: ________________________________________________________________________________
I have a beneficial interest in a land trust.
The name and address of the trustee is: ________________________________________________________________________
The beneficial interest is listed in my name and _________________________________________________________________
There is a mortgage on my real estate. State the mortgage company’s name and address for each parcel of real estate owned:
________________________________________________________________________________________________________
An assignment of beneficial interest in the land trust was signed to secure a loan from __________________________________
I have the following accounts:
Checking account at _____________________________; Checking account balance $ ________________________________
Savings account at ______________________________;
Savings account balance $ _________________________________
Money market or certificate of deposit at _____________ Safe deposit box at _______________________________________
Other accounts (please identify): _____________________________________________________________________________
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