INCOME AND ASSETS 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 any property of 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:
1. Name:______
2. Home Phone Number: ______
3. Home Address: ______
4. Date of birth: ______
5. Marital Status: ______
6. I have ______dependants.
7. Do you have a job? Yes No
8. Company’s name I work for: ______
9. Company’s address: ______
Job:
11. I earn $______per ______.
12. If self employed, list here your business name and address:
______
13. Income from self employment is $______per year.
14. I have the following benefits with my employer:
______
15. 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: $______per month
Real Estate:
16. Do you own any real estate? Yes No
17. I own real estate at ______, with names of other
owners: ______
18. Additional real estate I own:
______
19. I have beneficial interest in a land trust. The name and address of the trustee is:
______
20. The beneficial interest is listed in my name and ______.
21. There is a mortgage on my real estate:
State the mortgage company’s name and address for each parcel of real estate owned:
______
______
22. An assignment of beneficial interest in the land trust was signed to secure a loan
from: ______
23. I have the following accounts:
Checking account at: ______Account balance: $______
Savings account at: ______Account balance: $______
Money market or certificate of deposit at: ______
Safe deposit box at: ______
Other accounts (please identify): ______