Form 171-430 - Income And Asset Form - Lake County, Illinois Page 2
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2I 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 _________________________
______________________________________________________________________________________________ …………
III. OTHER ASSETS
I have the following accounts:
Checking account at: ___________________________________________________ ; Account balance: $ _________
Savings account at: ____________________________________________________ ; Account balance: $ _________
Money market or Certificate of Deposit at: __________________________________ ; Account balance: $ _________
Safe deposit box at: ____________________________________________________ ;
Other accounts: (please identify) ____________________________________________________________________
______________________________________________________________________________________________
I own:
A vehicle: (state year, make, model and VIN) __________________________________________________________
Jewelry (please specify) __________________________________________________________________________
Other property described as:
Stocks/Bonds ______________________________________________________________________________
Personal computer _________________________
DVD Player _________________________________
Television ________________________________
Stove ______________________________________
Microwave _______________________________
Work tools __________________________________
Business Equipment _________________________________________________________________________
Farm Equipment ____________________________________________________________________________
Other property (please specify) ________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
VERIFICATION BY CERTIFICATION
Under penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, the undersigned
certifies that the statements set forth in this instrument are true and correct, except as to matters therein stated to be on
information and belief, as to such matters the undersigned certifies as aforesaid he/she verily believes the same to be
true.
Date:______________, 20____
_______________________________________
Judgment Debtor
Page 2 of 2
171-430 (Rev. 08/12)
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