Income And Asset Form To Answer A Citation {21D(c)}

IN THE CIRCUIT COURT OF THE TWELFTH JUDICIAL CIRCUIT WILL COUNTY, ILLINOIS _______________________________________ Plaintiff vs CASE NO: _________________________________ _______________________________________ Defendant INCOME AND ASSET FORM TO ANSWER A CITATION 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 ____________________________ dependants. 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: _______________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ANDREA LYNN CHASTEEN, CLERK OF THE CIRCUIT COURT OF WILL COUNTY American LegalNet, Inc. www.FormsWorkFlow.com 21D (c-page 1) (Revised 12/16) I do not have a job, but I support myself through: Government Assistance: $______________________________ per month Unemployment: $________________________________ per month Social Security: $________________________________ per month SSI: $______________________________ per month Pension: $_____________________________ per month Other: _______________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 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 ____________________________________________________________________ account balance is $ ______________________________________ Savings account at _____________________________________________________________________ account balance is $ ______________________________________ Money market or certificate of deposit at ___________________________________________________ Safe deposit box at _____________________________________________________________________ Other accounts (please identify): __________________________________________________________ _____________________________________________________________________________________ I own: A vehicle (state year, make, model, and vin #): _______________________________________________ _____________________________________________________________________________________ Other property described as: ______________________________________________________________ Jewelry (please specify): _________________________________________________________________ _____________________________________________________________________________________ Stocks/Bonds: _________________________________________________________________________ Electronics: Personal computer: __________________________________________________________________ DVD: _____________________________________________________________________________ Television:_________________________________________________________________________ Other (please specify): _______________________________________________________________ __________________________________________________________________________________ ANDREA LYN