TITLE 20: CORRECTIONS, CRIMINAL JUSTICE, AND LAW ENFORCEMENT
CHAPTER VIII: TORTURE INQUIRY AND RELIEF COMMISSION
PART 2000 POLICY, HEARINGS AND FORMS
SECTION 2000.APPENDIX G APPLICATION AND ORDER FOR APPOINTED COUNSEL BASED UPON INDIGENCY

Section 2000.APPENDIX G   Application and Order for Appointed Counsel Based Upon Indigency

 

IN RE: TIRC Claim No.:

 

 

APPLICATION FOR APPOINTED COUNSEL BASED UPON INDIGENCY

 

I,

 

, on oath state:

 

1.

I am employed as a(n)

 

 

 

by

 

.

2.

My other sources of income (including spouse's income) or support are:

 

 

 

 

..

3.

The amount of income that I expect for this year is $

 

.

4.

My income for the previous year was $

 

.

5.

The persons dependent on me for support are

 

.

6.

My other sources of income are:

 SSI    Public Aid    SNAP Benefits  Family

 

 

Assistance    Foster Care    Aid to Aged, Blind and Disabled    Temporary

 

 

Assistance for Needy Families    General Assistance    State Transitional Assistance

 

 

 State Children and Family Services    Other:

 

 

 

 

$

 

(per month).

 

7.

The nature and value of property I own includes:

Real Estate (Describe property,

 

 

specify address, present value and mortgage liens outstanding.)

 

 

 

 

 

 

 

 

 

 Cash, Bank Accounts, etc. $

 

 Clothing and Jewelry $

 

 

 

 Motor Vehicle − Model

 

Year

 

Value $

 

 

8.

My monthly living expenses, including payments of debts and child support, are $

 

 

9.

I am unable to pay the cost of counsel for this claim and to do so would cause a substantial

 

 

hardship on me and my family.

 

Under penalties of perjury and/or contempt, the undersigned certifies that the statements set forth in this Application are true and correct, except as to matters therein stated to be on information and belief and as to such matters the undersigned certifies as aforesaid that s/he verily believes the same to be true.

 

 

 

 

 

 

 

 

Signature of Applicant

 

 

ILLINOIS TORTURE INQUIRY AND RELIEF COMMISSION

 

 

ORDER

 

 

IN RE: TIRC Claim No. :

 

       The Claimant, having demonstrated indigency, is appointed counsel for the limited purpose of advising Claimant regarding the Waiver procedure set forth in 2 Ill. Adm. Code 3500.350, and, if a Formal Inquiry is initiated pursuant to 2 Ill. Adm. Code 3500.375, regarding the Formal Inquiry as long as the Claim is pending before the Torture Inquiry and Relief Commission.  Counsel is appointed to advise Claimant only with regard to Claimant's pending Claim before the Commission, and not about any other legal matters Claimant may have.

 

       The Claimant's Application for appointed counsel is denied because the Application fails to demonstrate indigency.

 

 

 

 

 

Date

 

TIRC Chair