P1-Ci-013-E- Kane County Judicial Circuit - Application For Waiver Of Court Fees Page 2
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1
2
3(Application for Waiver of Court Fees continued)
Case No.
4. I checked "No" in section 3, so I am providing the following financial
In 4a., check
"Yes" if you have
information:
applied for at
least 1 of the
a. I have applied for 1 or more of the benefits listed in section 3:
benefits listed in
section 3.
Yes
No
In 4b., check the
box for each type
b. I receive the following money each month. This includes money received by people I
of money you
support who live with me.
have received in
(check all that apply)
the past month.
My employment:
$
Other people's employment:
$
Also enter the
gross (before
Child Support:
$
Social Security (not SSI):
$
taxes) amount for
each type.
Pension:
$
Unemployment:
$
Include the
money received
Other
:
$
by the people you
(list type and amount)
support who live
with you.
No Income
Support means
Total of all money received:
$
that the people
rely on you
financially.
c. I received the following total amount of money in the past 12 months. This includes
In 4c., check the
money received by people I support who live with me.
(check all that apply)
box for each type
of money you
My employment:
$
Other people's employment:
$
have received in
the past 12
Child Support:
$
Social Security (not SSI):
$
months.
For each type,
Pension:
$
Unemployment:
$
enter the total
amount received
Other
:
$
in the past 12
(list type and amount)
months before
taxes.
No Income
Include the
Total of all money received:
$
money received
by the people you
support who live
d. My current monthly expenses are listed below. This includes the monthly expenses of the
with you.
people I support who live with me.
(check all that apply)
In 4d., check all
of your expenses
Rent:
$
per month
for the past
month and list the
Home Mortgage:
$
per month
monthly amounts.
Include the
Other Mortgage:
$
per month
expenses of the
people you
Utilities:
$
per month
support who live
with you.
Food:
$
per month
Medical:
$
per month
Car Loan:
$
per month
Other
:
$
per month
(list type and amount)
I have no expenses
Total of all expenses:
$
Original - Clerk
Copy - Party
Copy - Party
P1-CI-013 (02/15) Page 2 of 3
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