Form 171-430 - Income And Asset Form - Lake County, Illinois
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2IN THE CIRCUIT COURT OF THE NINETEENTH JUDICIAL CIRCUIT
LAKE COUNTY, ILLINOIS
)
)
)
Judgment Creditor, )
vs.
)
Case. No.
)
)
)
Judgment Debtor.
)
INCOME 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. This 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.
I. JOB
Do you have a job? Yes No
Company’s name I work for: _____________________________________
Company’s address: _____________________________________________________________________________
Job: ____________________________________________
I earn: $ ________ per __________
If self-employed, list your business name and address: __________________________________________________
______________________________________________________________________________________________
Income from self-employment is: $ _______ per ________
I have the following benefits with my employer: ________________________________________________________
I do not have a job, but I support myself through:
Government Assistance
Unemployment $ _____ per month
$ _____ per month
Social Security
SSI
$ _____ per month
$ _____ per month
Pension
Other
$ _____ per month
$ _____ per month
II. REAL ESTATE
Do you own any real estate? Yes No
I own real estate at: _____________________________________________________ with names of other owner(s)
______________________________________________________________________________________________
Additional real estate I own: _______________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Page 1 of 2
171-430 (Rev. 08/12)
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